ArticleLiterature Review

Health and Health Care of Sexual and Gender Minorities

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Research on the social dimensions of health and health care among sexual and gender minorities (SGMs) has grown rapidly in the last two decades. However, a comprehensive review of the extant interdisciplinary scholarship on SGM health has yet to be written. In response, we offer a synthesis of recent scholarship. We discuss major empirical findings and theoretical implications of health care utilization, barriers to care, health behaviors, and health outcomes, which demonstrate how SGMs continue to experience structural- and interactional-level inequalities across health and medicine. Within this synthesis, we also consider the conceptual and methodological limitations that continue to beleaguer the field and offer suggestions for several promising directions for future research and theory building. SGM health bridges the scholarly interests in social and health sciences and contributes to broader sociological concerns regarding the persistence of sexuality- and gender-based inequalities.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Discrimination against LGBTQIA + communities extends into healthcare settings, with stigma as a central barrier to LGBTQIA + individuals accessing medical care [17]. In oncological settings, clinicians have varying levels of LGBTQIA + -specific expertise, awareness, and bias, which leaves standards of care and treatment trajectories variable for LGBTQIA + people with cancer seeking care [9][10][11]. ...
... One central mechanism for this is through clinicians and organizations providing affirming care tailored to the needs of LGBTQIA + cancer patients. However-with an established precedent of LGBT-QIA + people fearing discrimination by clinicians and this fear of discrimination directly impacting health-seeking behaviors and access to care [17,24]-it is essential that not only is affirming oncology care provided, but that LGBT-QIA + patients and families feel confident in identifying and accessing affirming oncology care. ...
... Adult and pediatric cancer centers' websites evidence great variability in their demonstration of LGBTQIA + inclusivity in online materials, and academic understanding of the implications for prospective LGBTQIA + patients is only in its infancy. For cancer centers, it is crucial that healthcare settings and clinicians work to convey LGBTQIA + inclusivity for their patients as a means of increasing the acceptability of and access to care for LGBTQIA + patients and families [7,17,36]. Improving website inclusivity is an important foundational step for healthcare systems in working towards this goal. In the spheres of academia and advocacy, it is important that further investigations on how healthcare settings communicate inclusivity for LGBTQIA + patients are conducted and that these findings are leveraged to improve conditions on micro-, mezzo-, and macro-scales. ...
Article
Full-text available
Purpose Cancer care for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexuality and gender diverse (LGBTQIA +) individuals is marked by disparities stemming from a history of discrimination, stigma, and systemic inequities. For LGBTQIA + individuals seeking cancer care, cancer center websites may be a first point of contact with healthcare. Two complementary studies sought to evaluate the LGBTQIA + inclusivity of cancer centers’ websites. Methods The authors conducted two studies in 2022–2023, reviewing the websites of National Cancer Institute (NCI)-designated cancer centers and Children’s Oncology Group (COG)-designated health systems and cancer centers. Reviewers manually searched websites and coded several Yes/No criteria for LGBTQIA + inclusivity. Results Among the 65 NCI cancer centers’ websites in 2023, 66% included a nondiscrimination statement, 71% mentioned LGBTQIA + health disparities, 65% included LGBTQIA + tailored resources, and 66% had articles about LGBTQIA + health. There was a trend of increased inclusivity across categories from 2022 to 2023. Among the 204 COG-designated health system websites in 2023, there were 60 pediatric care websites and 144 lifespan care websites. A total of 79.9% of COG health system websites referenced LGBTQIA + patients (80.0% of pediatric and 79.9% of lifespan sites), 16.7% of COG cancer center websites referenced LGBTQIA + patients in the context of cancer care (6.7% of pediatric and 20.8% of lifespan sites), and 82.4% yielded results when search terms were input (83.3% of pediatric and 81.9% of lifespan sites). Conclusions Adult and pediatric cancer centers’ websites have varying levels of LGBTQIA + inclusivity based on nondiscrimination statements, articles, and the availability of LGBTQIA + resources. While there have been some improvements in inclusivity on the NCI-designated cancer centers’ websites between 2022 and 2023, there is a need for further improvement.
... Research has shown that racial/ethnic minorities, sexual minorities, and cisgender/ heterosexual men are more likely to not have a usual source of care, skip preventive checkups, or delay needed medical care than people self-identified as White, heterosexual, and cisgender/heterosexual woman, respectively (Agénor et al., 2014;Dahlhamer et al., 2016;Hsieh & Shuster, 2021;Smedley et al., 2003;Springer & Mouzon, 2011). For example, compared to White Americans, Black, Native, Latinx/Hispanic, Asian, and Pacific Islander Americans are more likely to experience inadequate care because of economic barriers, racial prejudice, and discrimination in healthcare settings (Findling et al., 2019;Malat et al., 2010;Smedley et al., 2003). ...
... For example, compared to White Americans, Black, Native, Latinx/Hispanic, Asian, and Pacific Islander Americans are more likely to experience inadequate care because of economic barriers, racial prejudice, and discrimination in healthcare settings (Findling et al., 2019;Malat et al., 2010;Smedley et al., 2003). Relative to heterosexual individuals, lesbian, gay, and bisexual individuals have poorer access to healthcare due in part to a lack of financial security and health coverage and in part to provider insensitivity, prejudice, or discrimination against nonnormative sexuality (Badgett et al., 2019;Hsieh & Shuster, 2021;Sabin et al., 2015). Moreover, although masculinity garners more economic privilege than femininity, it is associated with fewer health-promoting beliefs and behaviors such as healthcare utilization, which explains why men tend to underutilize health services (Courtenay, 2000;Hsieh, 2024;Springer & Mouzon, 2011). ...
... Although having access to a PCP is critical to health maintenance and promotion in the U.S. healthcare system, not all U.S. populations have equal access to such a provider. Multiple forms of oppression may interact and reinforce one another to influence healthcare access and outcomes (Bowleg, 2021;Hsieh & Shuster, 2021). ...
Article
Full-text available
Not all U.S. populations have equal access to a primary care provider (PCP). This study presents one of the first population-based evidence of inequities in access to PCPs at the intersection of race/ethnicity, sexual orientation, and gender. We analyzed pooled data from the Behavioral Risk Factor Surveillance System from 2016 to 2021 across 42 states and 1 territory in the United States. The final sample encompassed 1,142,344 respondents aged 18 and older. Logistic regression models, stratified by gender spectrum, were estimated to compare predicted probabilities of having a PCP across 20 sexual and racial/ethnic identity groups. Among those on the feminine spectrum, most sexual minorities of color exhibited lower rates of having a PCP compared to heterosexual White individuals. Even when sociodemographic and health factors were accounted for, PCP access disadvantages remained significant in some groups of Native and Hispanic sexual minorities. Among sexual minorities of color on the masculine spectrum, inequities were less prominent, and sociodemographic and health factors nearly explained all their disadvantages. Sexual orientation, gender, and race/ethnicity intersect to shape the access to PCPs. Future research, policy designs, and clinical practices should adopt an intersectional approach to achieve a better understanding of healthcare inequities and to reduce inequities.
... Youth were not the only group who encountered barriers to prescribed HRT. Consistent with prior research, participants described inability to afford the medical appointments and lab testing required to receive HRT prescriptions; long wait lists; difficulty finding clinicians who are willing to prescribe HRT; and extensive gatekeeping (Baker et al., 2023;Hsieh, 2021;Linander et al., 2017). Participants emphasized that these barriers to care are manifestations of transphobia. ...
... Given that trans people frequently face workplace discrimination and, consequently, poverty (James et al., 2016;Hsieh, 2021), having DIY HRT as a comparatively affordable route for accessing medications is vital. ...
... Individuals who engage in same-sex sexual behavior are a unique subset of the general population, with known health disparities relating to stigma and discrimination [9,10] . In addition, they also have unique healthcare needs that may impact MS care, such as use of pre-exposure prophylaxis medications in men who have sex with men [11] . ...
... Regarding pharmacologic treatment, recent research has shown that men who have sex with men are far more likely than the general population to use pre-exposure prophylaxis medications or to have been immunized with the recent monkeypox vaccine, which may interact in unforeseen ways with common therapies for MS [11,12] . The gap in research for individuals engaging in same-sex behavior may be hindering the development of adequate treatment and identification strategies for this patient population already known to be at risk for negative health outcomes due to societal and health-care inequalities [8][9][10] . ...
Article
Full-text available
Adolescence is a critical window during which psychosocial factors have significant effects on the lifetime risk of multiple sclerosis (MS). Sexual behavior is relevant early in adulthood and has not been described in its relationship to MS. Using a retrospective secondary analysis of cross-sectional data in the TriNetX database, we investigated the connection between orientation of sexual behavior and MS risk. We identified 13,595 males and 9,589 females with same-sex behavior and 64,409 males and 137,450 females with opposite-sex behavior. Cohorts were balanced on age, race, and ethnicity. Males engaging in same-sex behavior had a 2.80-fold higher risk of MS diagnosis (95% confidence interval [CI]: 1.66 – 4.73), and females engaging in same-sex behavior had a 2.30-fold higher risk of MS diagnosis (95% CI: 1.65 – 3.20). Our findings thus advance the understanding of MS risk in the context of social determinants of health.
... Gender dynamics highly constrain medical encounters-influencing whether and how often a patient enters a medical space, shaping the patient-provider interaction, and even determining the degree of medical knowledge available on a particular ailment or concern (Bertakis, 2009;Hsieh & Shuster, 2021;Zimmerman & Hill, 2000). Accordingly, scholars have long examined the impact of gender in medicine and various social movements have mobilized to improve gender disparities in healthcare, particularly for cisgender (hereafter referred to as cis) women. ...
... There is also evidence of nonbinary patients being assigned a binary gender by providers, leading to stressful healthcare experiences (Shuster, 2016). However, the literature on how gender and sexual categories impact healthcare remains limited, and much of it focuses on people who were assigned male at birth, rendering a gap in extant knowledge of trans, nonbinary, and gender-nonconforming people who were assigned female at birth (AFAB) (Hsieh & Shuster, 2021). As such, this paper advances literature on health disparities and discrimination through an analysis of the healthcare experiences of trans men and AFAB nonbinary patients. ...
Article
Full-text available
Hysterectomy experiences among transmasculine individuals represent a powerful case to examine gendered dynamics in healthcare, especially given the continued cultural association between the uterus and womanhood. In this paper, I draw on theories from feminist science and technology studies and medical sociology to examine in‐depth interviews with 46 trans or nonbinary individuals who have had, want, or are considering an elective premenopausal hysterectomy. I find that trans men and nonbinary patients must negotiate what I call the structural feminization of gynecology which often leads to poor healthcare experiences. This paper also extends theories of a “patriarchal dividend” in medicine by examining reported differences in medical experiences when patients are perceived as cisgender women versus as trans men or nonbinary. I find a double bind inherent in the patriarchal divided in healthcare: masculinity often leads to better care, but the patriarchal dividend is constrained by the stigma introduced by being a trans patient. In the process, I extend social scientific knowledge of a highly common yet understudied procedure while expanding scholarship on medicine, gender, and embodiment.
... 12,13 However, there remains limited evidence in the differential physical health outcomes between these groups, largely due to the heterogenous methods employed between studies, and limited collection of data around sexual and gender minority identity within physical health studies. 3,5,[14][15][16][17] Intersectional minority identities can also compound poor outcomes; for instance, ethnic minority SGM groups report greater experiences of discrimination and harassment than white counterparts. 18,19 The United Kingdom's (UK) SM population is estimated to be at least 3.2% (1.5 million people), 20 and gender minority (GM) population at least 0.5% (262,000 people); 21 hence, the health inequities experienced by these groups represents a significant public health concern. ...
Article
Phenomenon: Sexual and gender minority (SGM) identifying individuals experience worse health outcomes compared to non-SGM identifying counterparts. Representation of SGM individuals within medical schools may improve the delivery of more equitable healthcare through reducing biases and normalizing SGM presence within healthcare spaces. Approach: Our initial aim was to explore the extent to which role models may influence personal SGM identities within medical schools in the United Kingdom, using an interpretative phenomenological approach. This methodology allowed us to develop meaning from, and give voice to participants’ relationship with their bespoke experiences, respecting differing narratives within the broad ‘SGM’ umbrella, rather than attempting to establish commonalities. Semi-structured interviews were conducted with five medical students and three medical school faculty within three medical schools, who identified as SGM. Due to a lack of gender minority identifying participants, we unfortunately could not adequately speak to their experiences, and therefore narrowed our eventual focus to sexual minority (SM) individuals. Findings: The developed themes followed a cyclical process of: (1) role model identification; (2) role model selection, influenced by matched wider identities including generation, hierarchy and power; (3) trait assimilation, particularly where identity deficits were perceived; and (4) identity projection, where students used role models to both emulate comfortable SM identity projection, and become advocatory role models themselves. Throughout, participants described role models as multifaceted in their direction (vertical and horizontal), influence (positive and negative) and locus of effect (as individuals, and as part of a collective). Unexpectedly, identity, power, and hierarchy-matching meant peer-to-peer role modeling was often experienced more positively than vertical faculty-to-student role modeling. However, as expected, heteronormativity exerted an inhibitory effect on this process. Insights: We built upon existing social cognitive paradigms to develop a ‘double-funnel’ model to represent how social contexts can map onto individual SM identities and vice versa, mediated by role models. The triangulation of these three aspects in relation to medical education presents novel understandings to the field. Greater explicit institutional support of student-led SM societies, and facilitation of the presence and discussion of SM symbols and personal identities within professional spaces, may go a long way in redefining ‘normativity’ in medical schools.
... People with Medicaid have reduced access to appointments compared to private insurance counterparts (66) and therefore are likely to wait longer to be seen and have fewer choices for their care. Similarly, SGM groups face discrimination in the healthcare setting, and for a variety of reasons have been found to be less adherent to treatment, visits with HCPs, and are less likely to receive preventive care which can increase need for emergency services (67). Despite race being a socially defined rather than biological construct, race and ethnicity are also used in clinical decision making and included in the American Society of Gastrointestinal Endoscopy (ASGE), American Gastroenterological Association (AGA), and American College of Gastroenterology (ACG) guidelines for screening and surveillance in H. pylori, Barrett's esophagus and gastric intestinal metaplasia respectively. ...
Article
Full-text available
Culture is a broadly defined term and patients’ cultural identity may show up in the medical setting in visible and invisible ways. In this paper, we aim to discuss cultural considerations in gastrointestinal (GI) care. Our definition of “culture” reflects the commonly ascribed race and ethnicity and will also discuss other minority groups such as sexual and gender minorities (SGMs). We will review what is known about rates of GI conditions across various cultural groups, acknowledging that our data reflect inequity in representation. While the healthcare system has overall shown an increased awareness of the role that systemic and institutional racism plays in affecting patient care, this has not been widely studied in the context of GI though has a profound impact. Multiple factors affect the interaction between patients’ cultural identities and engagement in and quality of GI care. Stigma related to cultural factors or cultural intersection has the capacity to shape if, when, and how medical care is approached, received and applied. Conditions and symptoms in GI are often complicated; health literacy (HL) is the ease with which patients can navigate getting from diagnosis to treatment and engage in self-management and also interacts with cultural context. Some aspects of a patient’s experience, background and skill are imperceptible and require the healthcare provider to attend to treatment with humility, respect and self-reflection if they wish to effectively engage. We introduce the concept of cultural humility to GI and offer practical suggestions for those providing clinical care. We also call for future investment in a diverse healthcare delivery system and continued legislation to promote social equity.
... For example, while increased service use may relate to increased need, it may also relate to an increased ability to navigate services. Third, the Alberta health administrative data uses a binary model of female/male sex, which limits the ability to identify inequities beyond differences between girls/women and boys/men, such as inequities among gender diverse/minority youth that have been previously documented [64]. Future work should engage with youth and families to contextualize findings and set them in real world experience. ...
Article
Full-text available
Background During the COVID-19 pandemic, youth had rising mental health needs and changes in service accessibility. Our study investigated changes in use of mental health care services for Canadian youth in Alberta before and during the COVID-19 pandemic. We also investigated how youth utilization patterns differed for subgroups based on social factors (i.e., age, gender, socioeconomic status, and geography) previously associated with health care access. Methods We used cross-sectional population-based data from Alberta, Canada to understand youth (15–24 year) mental health care use from 2018/19 to 2021/22. We performed interrupted time series design, segmented regression modeling on type of mental health care use (i.e., general physician, psychiatrist, emergency room, and hospitalization) and diagnosis-related use. We also investigated the characteristics of youth who utilized mental health care services and stratified diagnosis-related use patterns by youth subgroups. Results The proportion of youth using mental health care significantly increased from 15.6% in 2018/19 to 18.8% in 2021/22. Mental health care use showed an immediate drop in April 2020 when the COVID-19 pandemic was declared and public health protections were instituted, followed by a steady rise during the next 2 years. An increase was significant for general physician and psychiatrist visits. Most individual diagnoses included in this study showed significant increasing trends during the pandemic (i.e., anxiety, adjustment, ADHD, schizophrenia, and self-harm), with substance use showing an overall decrease. Mortality rates greatly increased for youth being seen for mental health reasons from 71 per 100,000 youth in 2018/19 to 163 per 100,000 in 2021/22. In addition, there were clear shifts over time in the characteristics of youth using mental health care services. Specifically, there was increased utilization for women/girls compared to men/boys and for youth from wealthier neighborhoods. Increases over time in the utilization of services for self-harm were limited to younger youth (15–16 year). Conclusions The study provides evidence of shifts in mental health care use during the COVID-19 pandemic. Findings can be used to plan for ongoing mental health needs of youth, future pandemic responses, and other public health emergencies.
... Our programme aimed to overcome these challenges by respecting the communication preferences of clients, delivering HIVST kits to any address clients chose, wrapping kits in discreet packaging and ensuring clients were contacted with the same VC throughout the process to support building trust. Our programme's experience adds to global evidence demonstrating the need for public health services to promote privacy for sexual and gender minority groups [18,26]. ...
Article
Full-text available
Introduction To achieve epidemic control of infectious diseases, engaging higher‐burden populations with accessible diagnostic services is critical. HIV self‐testing (HIVST) is a promising option. Methods We implemented an online HIVST programme for key populations across India. Eligible clients were 18 years or older, self‐reported a negative or unknown HIV status and reported not taking antiretroviral therapy. Clients who reported a prior HIV diagnosis were not eligible to receive an HIVST kit. HIVST clients received kits via courier or in person at pre‐determined pick‐up points supported by trained counselling staff. Virtual counsellors engaged clients online and by phone and offered support to register, access, and complete HIVST free of cost. Virtual counsellors supported clients to report results and engage with follow‐up services. Follow‐up included linking clients with a positive result to confirmatory testing and HIV care services. We assessed programmatic data across HIV continuum outcomes and conducted a qualitative evaluation through interviews with purposively sampled clients. Results Between 30 June 2021 and 30 September 2022, 5324 clients ordered an HIVST kit (76% men, 13% women, 7% transgender people, 4% unknown gender). Of the 4282 clients reporting results (94% of those who received a kit), 6% screened positive, among whom 72% (n = 184) completed confirmatory testing. Themes from 41 client interviews included satisfaction about the convenience and privacy of services and the discreet nature of kit delivery. Respondents were drawn to the convenience of HIVST and appreciated gaining courage and comfort throughout the process from virtual counsellor support. For respondents who screened positive, challenges to care linkage included fearing judgemental questions from public providers and wanting more time before starting treatment. Clients shared concerns about kit accuracy and suggested that instructional materials be provided with more diverse language options. Conclusions Web‐based HIVST services with tailored support appeared to facilitate HIV service access and engagement of harder‐to‐reach populations across India. Assistance from a community‐oriented counsellor proved important to overcome literacy barriers and mistrust in order to support the HIVST process and service linkage. Learnings can inform global efforts to improve the critical step of diagnosis in achieving epidemic control for HIV and other infectious diseases.
... Mortality due to cardiovascular disease is higher in men in Asia [49]; conversely, in Europe, it is higher in women [50]. Sex differences in diseases can be caused by various factors, such as physiological factors, socioeconomic environment, cultural factors, regional and racial characteristics, and customs; additionally, obtaining healthcare may be more difficult for women than for men [51]. In a cross-sectional survey of more than 10,000 Chinese participants, the prevalence of MS according to SES was analyzed. ...
Article
Full-text available
A high prevalence of metabolic syndrome (MS) and cardiovascular disease among low-income individuals has often been reported. However, there is still a lack of research on the relationship between basic livelihood security (BLS) and MS. This study investigated the prevalence of MS according to activity type, dietary habits, and the nutrient intake characteristics of individuals receiving BLS. Data from 14,803 men and 20,299 women were analyzed to assess the association between receiving BLS and MS. The associations between MS and various factors were analyzed separately in men and women by logistic regression analysis. In this cohort, 5.9% of men and 6.8% of women received BLS; of these, 46.9% and 47.7% had MS, respectively. High caloric intake, low-frequency breakfast consumption, and no nutritional education were associated with MS in both men and women. Among those with a low-frequency walking habit and strength training activity type, MS increased by 1.58 and 1.57 times in men and by 1.47 and 2.16 times in women, respectively. Men who were sedentary for 8 h or more had an increased risk of MS, but there was no association between these in women. BLS nutritional intake characteristics were high in carbohydrates and fat and low in dietary fiber and vitamin C (p < 0.05). In conclusion, establishing a healthy eating pattern through nutritional education and increasing walking and strength training may reduce the risk of MS.
... Here, our findings highlight how the health system remains critically driven by normative and institutional barriers that influence health providers' attitudes and behaviors when addressing situations (e.g., expressing more than one need or a need that is beyond the scope of the consulted service) and individuals who are unfamiliar with providing integrated care in their routine clinical practices. As described in recent reviews (Hsieh & Shuster, 2021;Mitchell et al., 2023), the discourses surrounding gender and sexual normativity continue to negatively influence health care access and utilization for SGM people. As such, these data underscore how SGM-tailored integrated models of care will need to carefully account for and address the social and structural factors that drive oppressive practices within health care systems and service delivery practices. ...
Article
Full-text available
Background: Despite well-established evidence showing that young sexual and gender minority (SGM) men experience disproportionate mental health and substance use inequities, few sexual health services provide mental health and substance use care. This qualitative study examined the experiences and perspectives about integrated care models within sexual health services among young SGM men experiencing mental health and substance use challenges. Methods: Semi-structured interviews were conducted with 50 SGM men aged 18–30 years who reported using substances with sex in Vancouver, Canada. Interviews were analyzed using thematic analysis. Results: Three themes were identified: 1) participants asserted that their sexual health, mental health and sub- stance use-related health needs were interrelated and that not addressing all three concurrently could result in even more negative health outcomes. These concurrent health needs were described as stemming from the oppressive social conditions in which SGM men live. 2) Although sexual health clinics were considered a safe place to discuss sexual health needs, participants reported not being invited by health providers to engage in discussions about their mental health and substance use health-related needs. Participants also perceived how stigmas associated with mental health and substance use limited their ability to express and receive support. 3) Participants identified key characteristics they preferred and wanted within integrated care, including training for health providers on mental health and SGM men’s health and connections (e.g., referral processes) between services. Participants also recommended integrating social support programs to help them address SGM-related social challenges. Conclusion: Our findings highlight that SGM men’s sexual health, mental health and substance use-related health needs and preferences are interrelated and should be addressed together. Tailored training and resources as well as structural adaptations to improve communication channels and collaborative connections between health providers are required to facilitate the development of integrated care for young SGM men.
... [6][7][8][9] While disparities have been examined in relation to SOGI and geography, little research focuses on the intersection of SOGI and = and rurality. [10][11][12] This paucity is observed in the lack of data regarding rural LGBTQ + individuals as it compares to urban areas and even their rural cisgender heterosexual peers. Still, at least one study reports that rural LGBTQ + may have worse self-reported health measures than their rural non-LGBTQ + peers. ...
Article
Full-text available
Purpose To describe healthcare experiences and health outcomes among rural LGBTQ + individuals. Design 2022 cross-sectional survey. Setting Southern Illinois. Sample 85 individuals. Measures Demographics, sexual orientation and gender identity, healthcare experiences, health outcomes. Analysis Experiences and outcomes were assessed vs orientation and identity. Distribution comparison was by t-test and chi-square, risk prediction by logistic regression, and significance assumed at P < .050. Results By orientation, participants were: 35.3% gay, 16.5% lesbian, and 45.8% bisexual plus; and by identity they were: 49.4% cisgender, 25.9% transgender, and 24.8% other identity. Survey item responses ranged from 95%-99%. Compared to gay men, lesbians and bisexual plus individuals more frequently reported medical bill payment difficulty (58.3% and 57.9% vs 25.0%; P = .020) and more past month days of poor mental health (19.4 and 15.8 vs 10.6; P = .018). Compared to heterosexual and other identity, transgender individuals less frequently reported having a routine medical provider (72.7% vs 92.7% and 95.0%; P = .037) and more frequently reported past healthcare denial (45.5% vs 17.5% and 18.8%; P = .042). Current health was associated with medical bill payment ability (OR = .33, 95% CI = .13-.86) and respectful treatment by healthcare administrators (OR = 3.90, 95% CI = 1.34-11.35) and clinicians (OR = 3.82, 95% CI = 1.39-10.47). Significance of some findings likely limited due to sample size. Conclusions Our data describes healthcare experience and health outcome disparities among rural lesbian, gay, bisexual, transgender, queer and other sexual and gender minority individuals, and indicate that clinical experiences directly influence health outcomes.
... The stigma and discrimination faced by MSM, both within society and health care settings, contribute to hesitancy in seeking mental health support. This fear of stigma and reluctance aligns with the findings from studies of various marginalized populations [26,[31][32][33]. In response to this, participants expressed a preference for features within the mobile app that could link participants with LGBTIQA+-friendly mental health professionals through video sessions, automated text messages, or phone calls, emphasizing the crucial role of trust and understanding in the provider-patient relationship. ...
Article
Full-text available
Background Men who have sex with men (MSM) are disproportionately burdened by poor mental health. Despite the increasing burden, evidence-based interventions for MSM are largely nonexistent in Nepal. Objective This study explored mental health concerns, contributing factors, barriers to mental health care and support, and preferred interventions to improve access to and use of mental health support services among MSM in Nepal. Methods We conducted focus groups with MSM in Kathmandu, Nepal, in January 2023. In total, 28 participants took part in 5 focus group sessions. Participants discussed several topics related to the mental health issues they experienced, factors contributing to these issues, and their suggestions for potential interventions to address existing barriers. The discussions were recorded, transcribed, and analyzed using Dedoose (version 9.0.54; SocioCultural Research Consultants, LLC) software for thematic analysis. Results Participants reported substantial mental health problems, including anxiety, depression, suicidal ideation, and behaviors. Contributing factors included family rejection, isolation, bullying, stigma, discrimination, and fear of HIV and other sexually transmitted infections. Barriers to accessing services included cost, lack of lesbian, gay, bisexual, transgender, intersex, queer, and asexual (LGBTIQA+)–friendly providers, and the stigma associated with mental health and sexuality. Participants suggested a smartphone app with features such as a mental health screening tool, digital consultation, helpline number, directory of LGBTIQA+-friendly providers, mental health resources, and a discussion forum for peer support as potential solutions. Participants emphasized the importance of privacy and confidentiality to ensure mobile apps are safe and accessible. Conclusions The findings of this study have potential transferability to other low-resource settings facing similar challenges. Intervention developers can use these findings to design tailored mobile apps to facilitate mental health care delivery and support for MSM and other marginalized groups.
... These barriers have historically included a mistrust of medical providers and researchers, impacting the participation of SGM of colour in HIV prevention research (Andrasik et al., 2014). Experiences of stigma and discrimination have been shown to be associated with poor utilisation of HIV prevention services among SGM of colour (Eaton et al., 2015;Hsieh & Shuster, 2021;Rice et al., 2021;Zapata et al., 2022). Discrimination from healthcare providers often leads transgender people to 'selectively disclose' their identity based on their provider's attitude (Kcomt, 2019, p. 203). ...
... Concurrently, the trans population remains largely absent from both broad and trans-specific medical discourse and research (Reisner et al., 2016). Studies have shown how this results in health disparities such as lack of official treatment protocols and medical training regarding trans-related healthcare, absence from clinical trials, and prevalence of medical transphobia (Cicero et al., 2019;Hsieh and Shuster, 2021;McCormick, 2020;Willging et al., 2019). These disparities have been met with various forms of activism by the trans community, such as demands for trans depathologization and raising awareness of institutional violence, which despite some success, did not lead to wide-spread institutional changes (Hanssmann, 2020;Suess Schwend, 2020). ...
... Given that previous research has found that gender disparities in mental health exist in the United States (21,22) and that better practices in gender identity measurement have not yet been widely adopted (CITE-me and others), there is an urgent need to report any findings that may begin to identify clinical targets to improve outcomes for those who identify as transgender. This study aimed to describe different factors affecting mental health and substance use patterns among transgender-vs. ...
Article
Full-text available
Introduction This study describes the differences and similarities in mental health, substance use, and substance use treatment outcomes between people presenting for SUD treatment who identified as transgender and those who identified as cisgender men or women. Methods We compared 64 individuals who self-identified as transgender and presented for SUD treatment to samples of cisgender men and women (separately) matched based on propensity scores which were created based on sociodemographic factors known to influence both the nature of substance use and patterns of treatment engagement including age, education, race, stable housing, and employment status. Comparisons were made using χ² tests and t-tests in over 150 variables collected at treatment intake regarding physical and mental health, substance use patterns, events that led to treatment, reasons for seeking treatment, and treatment outcomes. Results The transgender sample endorsed six of the seven suicide-related items more often than at least one of the cisgender-matched samples. Furthermore, the transgender sample remained in treatment significantly longer (M = 32.3, SD = 22.2) than the cisgender male sample (M = 19.5, SD = 26.1, t = 2.17, p = 0.03). Discussion This study is a first step into understanding gender minority population experiences during SUD treatment. While there was no significant difference between the cisgender and transgender samples on most variables, there was an elevated prevalence of suicidal ideation and behaviors in the transgender sample, which warrants further investigation.
... Participants' sexual orientation was measured by a single-option question with 6 items: "Which of the following better describes your sexual orientation?" Except for heterosexuality, all other sexual orientations are combined to form the sexual minority youth group [41,42], which was then further divided into 3 subgroups, including homosexuality (gay or lesbian), bisexuality, and others (asexuality, pansexuality, and uncertain). Anxiety was measured by the 7-item Generalized Anxiety Disorder Questionnaire [43], depression by the 9-item Patient Health Questionnaire [44], and PTSD by the 10-item Trauma Screening Questionnaire [45]. ...
Article
Full-text available
Background Bullying victimization is highly prevalent among sexual minority youths, particularly in educational settings, negatively affecting their mental health. However, previous studies have scarcely explored the symptomatic relationships among anxiety, depression, and posttraumatic stress disorder (PTSD) among sexual minority youths who experienced bullying on college campuses. Objective The objectives of our study were to (1) characterize the anxiety-depression-PTSD network structures of gay or lesbian, bisexuals, and other sexual minority youths previously bullied on college campuses; and (2) compare symptomatic associations in the anxiety-depression-PTSD networks among bullied sexual minority youths and heterosexual youths’ groups. Methods This cross-sectional study recruited college participants from Jilin Province, China. Data were analyzed using a subset of the data extracted after screening for sexual orientation and history of bullying victimization. Sexual minority youths were then divided into 3 subgroups: gay or lesbian (homosexual), bisexual, and other. Mental health symptom severity was assessed using scales: the 7-item Generalized Anxiety Disorder Scale measuring anxiety, the 9-item Patient Health Questionnaire measuring depression, and the 10-item Trauma Screening Questionnaire measuring PTSD symptoms. Combining the undirected and Bayesian network analyses, the anxiety-depression-PTSD networks were compared among sexual minority youths subgroups, and the difference between heterosexual youths and sexual minority youths was investigated. Chi-square tests were used to compare the difference in categorical variables, while independent-sample t tests were run on continuous variables. Results In this large-scale sample of 89,342 participants, 12,249 identified as sexual minority youths, of which 1603 (13.1%, 95% CI 12.5%-13.7%) reported being bullied on college campuses in the past year. According to the expected influence (EI) and bridge expected influence (bEI) index, in the global network structure of anxiety, depression, and PTSD, sad mood (EI=1.078, bEI=0.635) and irritability (EI=1.077, bEI=0.954) were identified as central and bridge symptoms; emotional cue reactivity (EI=1.015) was a central symptom of PTSD in this global network. In the anxiety-depression-PTSD Bayesian network, anhedonia had the highest prediction priority for activating other symptoms; and feeling afraid linked symptoms from anxiety to the PTSD community. Compared to their heterosexual counterparts, sexual minority youths exhibited a stronger association between difficulty concentrating and appetite. The “sad mood-appetite” edge was strongest in the gay or lesbian network; the “irritability-exaggerated startle response” edge was strongest in the bisexual network. Conclusions For the first time, this study identified the most central and bridge symptoms (sad mood and irritability) within the depression-anxiety-PTSD network of sexual minority youths with past bullying-victim experiences on college campuses. Emotional cue reactivity, anhedonia, and feeling afraid were other vital symptoms in the comorbid network. Symptomatic relationships existed showing heterogeneity in bullied heterosexual youths and sexual minority youth networks, which also was present within the sexual minority youth subgroups. Consequently, refined targeted interventions are required to relieve anxiety, depression, and PTSD symptoms.
... Although there is speculation that the effects of the pandemic have not been evenly distributed throughout society, with greater stresses on those who are most marginalized and disadvantaged (Salerno et al., 2020), there are relatively few empirical studies and not many relying on nationally representative samples. The COVID-19 dashboards and official statistics did not report differentials in hospitalization and mortality, but there appeared to be differences in mental health, substance use, and suicidal ideation among populations at increased risk of psychological distress (Czeisler et al., 2020), as well as inequalities in health and healthcare among sexual and gender minority people (Gibb et al., 2020;Hsieh and Shuster, 2021). ...
Article
Full-text available
Emotional support, particularly support from family and friends, is essential to health outcomes especially for marginalized communities. Although emotional support is recognized as a critical resource, especially during the COVID-19 pandemic, to date no research has examined access to support during the pandemic for sexual diverse populations. This study aims to apply minority stress theory by drawing on a new population-based data source of 3,642 respondents, the National Couples' Health and Time Study (NCHAT), which oversampled sexual and gender diverse populations during the pandemic. We focus on two sources of emotional support: family members and friends. Exclusively heterosexual respondents relied more on emotional support from family than respondents who identified as exclusively gay/lesbian, bisexual including pan, omni, and queer, and those reporting another sexual identity or multiple sexual identities. However, respondents who did not identify as heterosexual relied more on emotional support from friends compared to exclusively heterosexual respondents. There were no significant differences among respondents with sexual minority identities in regard to family or friend support. Other factors, such as outness to friends and family, identity centrality, aggressions, and relationship satisfaction are found to be associated support from friends and family. The findings presented here add to a growing body of work on social support while adding sexual minority-specific factors that may affect receipt of, need for, and outcomes relating to support. This work contributes to understanding of the social climate and resources available to sexual diverse populations during a major public health crisis.
Article
Background: Prior research has shown that advance care planning (ACP) knowledge and discussion varies among racial and ethnic groups. However, little is known if similar disparities exist within the sexual minority (SM) population. Objectives: To investigate racial disparities in ACP knowledge, discussion, and decision making within the SM population. Methods: Data from an online survey (N = 281) asked Black and White SM adults ages 50+ about their knowledge and actions about future healthcare wishes and their healthcare experiences. A series of multivariable logistic regressions were conducted to examine the association between ACP knowledge, discussion, and medical decision-making and race, while adjusting for other demographic and health-related variables. Results: On average, respondents were 57 years old (SD = 6.04) and just over half identified as being White (52%) and as men (55%). Most participants had heard of ACP (74%) and had an ACP discussion with someone (65%). Sixty-six percent of participants were very comfortable with medical decision-making. White SM adults had higher odds of having ACP knowledge (aOR = 3.56; 95% CI = 1.78, 7.07) and discussions (aOR = 2.43; 95% CI = 1.28, 4.61). While no racial differences were found in comfort with medical decision-making, other sociodemographics were significantly associated with comfort with medical decision-making. Conclusion: Outcomes from this work indicate persistent racial disparities in ACP within the SM population in addition to highlighting other factors that influence ACP. These findings emphasize the need for resources to address this systemic issues and to ensure that SM adults have access to and engage in ACP.
Article
Full-text available
In this article, we examine Anna-Marie McLemore’s When the Moon Was Ours (2016) through the theory of Queer Transgressive Cultural Capital. In doing so, we argue that queer and trans characters subvert existing Westernized systems of care, which are frequently reified in existing queer and trans young adult literature. We first explore how McLemore’s text uses magical realism to disrupt common trans narratives in Western contexts, in addition to exposing the norms that continue to haunt contemporary queer texts. Next, we draw from the history of trans medicine in Western contexts to examine how multiple characters in McLemore’s novel use their cultural knowledge and practices to examine their identities, think about their gender and sexuality outside of Western models of care and medicine, and challenge the normative ideals that threaten queer and trans lives, both real and fictional. Lastly, we consider When the Moon Was Ours’ potential to challenge the norms of whiteness, medicine, and the body present in the larger corpus of YA literature. We end with a consideration of the implications of teaching When the Moon Was Ours and including trans narratives in the classroom.
Article
Self-rated health (SRH) is consistently related to mortality and morbidity. Yet, health ratings are subjective and reflect an individual's social context. Prior work has found differences in the structure of SRH—that is, in how self-assessments relate to underlying health conditions—across social groups, including by gender. However, prior work has not included transgender adults despite evidence that widespread interpersonal and structural stigma uniquely shapes their subjective experience of health. This study draws on information about 12 health conditions for a sample of transgender men, transgender women, nonbinary adults, cisgender men, and cisgender women. It examines whether the probabilities of reporting poor or fair SRH are similar among those with various underlying health problems. Findings reveal differences by gender identity and age group. For more than half of the examined conditions, self-rated health is poorer among nonbinary adults and younger transgender men than among other gender groups. These differences likely reflect distinct self-assessment processes that consider minority stress and structural stigma, as well as underlying differences in severity and comorbidity that stem from such stigma processes. SRH remains a useful, holistic measure of well-being, including for transgender groups.
Article
Background While the significance of care navigation in facilitating access to health care within the lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) communities has been acknowledged, there is limited research examining how care navigation influences an individual’s ability to understand and access the care they need in real-world settings. By analyzing private sector data, we can bridge the gap between theoretical research findings and practical applications, ultimately informing both business strategies and public policy with evidence grounded in real-world efficacy. Objective The objective of this study was to evaluate the impact of specialized virtual care navigation services on LGBTQ+ individuals’ ability to comprehend and access necessary care within a national cohort of commercially insured members. Methods This case study is based on the experience of commercially insured members, aged 18 or older, who used the LGBTQ+ Health Care Navigation (LGBTQ+ Navigation) service by Included Health between January 26 and July 31, 2023. Care coordinators assisted members by connecting them with vetted identity-affirming in-network providers, helping them navigate and understand their LGBTQ+ health benefits, and providing education and advocacy for clinical and nonclinical needs. We examined the impact of navigation on 5 member-reported outcomes. In addition to reporting the proportion who agreed or strongly agreed, we calculated an impact score that averaged assigned numerical values to all 5 question responses (1=strongly disagree to 5=strongly agree) for each respondent. We used ANOVA with Tukey post hoc tests and t tests to explore the relationships between the impact score and member characteristics, including optional self-reported demographics. Results Out of 4703 LGBTQ+ Navigation cases, 7.53% (n=354) had member-reported outcomes. A large majority of LGBTQ+ members agreed or strongly agreed that care navigation resulted in less stress (315/354, 89%), less care avoidance (305/354, 86.2%), higher confidence in finding an identity-affirming provider (327/354, 92.4%), improved ability to comprehend health care information (312/354, 88.1%), and improved ability to engage with providers (308/354, 87%). The average impact score was 4.44 (SD 0.69), with statistically significant differences by gender identity ( P =.003), race ( P =.01), ethnicity ( P =.008), and pronouns ( P =.02). The scores were highest for members with multiple gender identities (mean 4.56, SD 0.37), and members who did not provide their race, ethnicity, or their pronouns (mean 4.55, SD 0.64). Impact scores were lowest for transgender members (mean 4.11, SD 0.95). Conclusions The LGBTQ+ Navigation service, by enhancing members’ comprehension and use of necessary care, demonstrates potential public health utility and value. Continuous evaluation of navigation services can serve as a supplementary tool for employers seeking to promote health equity and improve belonging among employees. This is particularly important as discrimination and stigma against LGBTQ+ communities persist in the United States. Therefore, scalable and system-level changes that use navigation services are essential to reach a larger proportion of the LGBTQ+ population.
Article
Objectifs Les objectifs de cet article sont d’explorer les caractéristiques psychopathologiques, cognitives et psychologiques des minorités sexuelles d’âge avancé telles que les personnes homosexuelles, bisexuelles et asexuelles. Et ce, sous le prisme du vieillissement, des stigmatisations, des facteurs protecteurs et des ressources adaptatives spécifiques aux minorités sexuelles. Méthode La revue de littérature a été réalisée sur les bases de données EBSCOHOST et CAIRN. Résultats Les minorités sexuelles âgées présenteraient plus de symptômes et troubles dépressifs et anxieux ainsi que de troubles du stress post-traumatiques. Des différences de capacités cognitives ont également été observées. Ces disparités sont expliquées par l’effet des facteurs de stress minoritaires qui viennent s’ajouter aux facteurs de stress communs à l’ensemble de la population. Les minorités sexuelles âgées auraient moins de symptômes que les minorités sexuelles plus jeunes. Cette asymétrie serait expliquée par l’expertise des minorités sexuelles âgées dans la capacité à faire face à l’hétérosexisme. Elles développeraient tout au long de la vie des stratégies de coping efficaces permettant, au grand âge, de se confronter à l’âgisme. La perception positive de l’identité sexuelle jouerait un rôle central dans la capacité à faire face. Le réseau social, tout particulièrement la famille choisie, est un important outil de soutien émotionnel. Conclusion Les recherches actuelles en psychopathologie permettent de souligner la nécessité de prendre en compte à la fois le processus de vieillissement, les spécificités minoritaires ainsi que les ressources individuelles dans l’étude de la santé mentale des minorités sexuelles âgées. De futures recherches devraient se concentrer sur l’investigation des spécificités de la population française, des interactions entre vieillissement et stress minoritaires ainsi que sur l’évolution des caractéristiques minoritaires par le biais d’études longitudinales.
Article
Background Despite numerous calls for standardized collection of sexual orientation and gender identity (SOGI) data in clinical settings, uptake of this practice still lags. Objectives This study conducted a preimplementation assessment of staff attitudes toward SOGI data collection within an adult primary care practice in an urban academic medical center in the northeastern United States. Research Design We created a process map of the flow of patient data from the point of registration to the clinical encounter to identify all staff roles associated with registration and patient demographic data collection. We purposively sampled staff members across these roles and conducted semistructured virtual interviews between November 2021 and February 2022. The research team used deductive and inductive coding and conducted a thematic analysis to identify barriers and facilitators to implementation. Subjects Nine clinical staff and eleven nonclinical staff were interviewed. Measures Participants were asked about their general experiences with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients, their perspectives on collecting this data, and potential barriers and facilitators to incorporating this into the workflow. Results The main themes that emerged were the relevance of SOGI data to the clinical practice; concerns about patient acceptability; the prevalence of cis-gender, heteronormative assumptions; and concerns about linguistic, cultural, and generational differences. Differences were noted between clinical and nonclinical staff. Conclusions Greater education is needed to help both clinical and nonclinical staff understand how patients’ SOGI demographics can be used to provide affirming, patient-centered care. Implementation strategies can be tailored to address specific barriers at the individual, organizational, and social levels.
Article
Full-text available
In examining the gender distribution within the healthcare workforce as reported by the Executive Yuan in February 2021, it was found that 28.1% of the practitioners are male, while 71.9% are female. However, in the female-dominated healthcare sector, only 30.1% of physicians are female, a percentage lower than that in many other countries. Despite the inclusion of gender issues in the continuous education curriculum for physicians after the 2007 amendment to the "Regulations on Medical Practitioners' Registration and Continuing Education," the promotion and attention to gender issues in the medical field still require further progress. Sexual harassment remains a prominent gender issue. The incident involving a nurse at Linkou Chang Gung Memorial Hospital, who was harassed by a physician, highlights the longstanding presence of sexual harassment in the medical workplace. The implementation of the three gender equality laws ("Gender Equality in Employment Act," "Gender Equity Education Act," and "Sexual Harassment Prevention Act") over the past two decades has increased societal and governmental attention to gender-related issues. Significant strides have been made, such as Taiwan becoming the first Asian country to legalize same-sex marriage in 2019 and the Ministry of Labor extending paternity leave from five to seven days in 2022. Sexual harassment and gender inequality are interconnected issues in the healthcare workplace, with disparities in pay and promotion opportunities creating environments where harassment becomes prevalent. Ending such inequalities requires comprehensive measures including standardized reporting channels, prevention strategies, routine education, and addressing organizational factors contributing to harassment. Additionally, the recognition of diverse gender identities, such as LGBTQ+ individuals, has brought related issues into the public eye. Guidelines for providing a friendly healthcare environment for LGBTQ+ individuals include respecting their identities and ensuring privacy and confidentiality during consultations. In conclusion, while Taiwan appears progressive in gender consciousness and equality, significant improvements are still necessary. Addressing workplace sexual harassment and recognizing diverse gender issues are essential steps towards creating a more inclusive and equitable society and medical environment.
Article
Full-text available
Since the legalization of same-sex marriage in Taiwan in May 2019, Taiwanese citizens have become increasingly aware of the concerns of sexual minorities. One subgroup of sexual minorities that continues to be underappreciated is transgender individuals. This article offers several recommendations for sensitively interacting with transgender individuals, such as not emphasizing their biological sex, refraining from outing individuals against their wishes, and avoiding inappropriate words of praise. In both clinical and daily settings, respecting gender identity and avoiding stereotypes helps establish a friendly and respectful atmosphere.
Article
Parent mental health challenges in the postpartum and early parenthood have profound implications for parent, child, and family well‐being. Little research has focused on postpartum mental health challenges and barriers to help‐seeking among queer birthing people, including members of this community who may be particularly vulnerable to mental health difficulties, such as queer cis women partnered with men, trans/nonbinary parents, and queer parents who are young, low‐income, and/or of color. This mixed‐methods study of queer parents ( n = 99), all of whom were assigned female at birth (AFAB) and gave birth to a child within the past several years, explores parents' postpartum mental health difficulties and perceived barriers to seeking help. Using a structural stigma framework, this study found that participants reported high rates of postpartum mental health difficulties (89%) and reported various barriers to seeking support including fears of discrimination and being deemed “unfit” by providers, which might lead to child welfare system involvement. Young parents and low‐income parents were particularly fearful of child welfare system contact and potential child removal. Factors that encouraged help‐seeking (e.g., desire to be a good parent; partner pressure to seek help) and implications for family practitioners are discussed.
Article
Sexual minorities are a rapidly growing population, with recent estimates showing a two-fold increase in the percentage of sexual minorities over the past decade. Working with relatively few measures to identify sexual minorities, social scientists have amassed an impressive amount of evidence on inequality by sexuality. Despite this remarkable work, I argue that it is important to take a step back analytically and re-assess sexual minorities from a descriptive standpoint. Using population-level data from the CDC’s Behavioral Risk Factor Surveillance System, I provide unadjusted estimates of sociodemographic, socioeconomic, and family characteristics by sexual identity. Results reveal that sexual minorities are younger, are more racially diverse, and concentrate in different parts of the country than heterosexuals. Similarly, sexual minorities have remarkably different socioeconomic lives than heterosexuals, who enjoy higher annual household incomes, achieve higher educational attainment, and are more likely to be homeowners. Sexual minorities are also less likely to be married than heterosexuals. I conclude by highlighting that descriptive research can illuminate compositional differences between sexual minorities and heterosexuals; provide rationales for adjusting for certain characteristics that might confound relationships between sexual identity and numerous outcomes; and highlight potential explanatory mechanisms to make better sense of well-established findings regarding sexual minority disadvantage.
Article
Trans people’s gender identity is frequently cited as a source of health care denial, even when it has no bearing on their symptom presentation. A latent belief among health care workers that trans people are fundamentally different from cis people is deeply implicated in the finding that between one fifth and one third of trans people have been denied care because of their gender identity. In this study, the authors use data from a nationally representative survey ( n = 2,458) to examine whether Americans believe a doctor who denies care to a trans patient on the basis of claims of inadequate training. The authors find a majority of Americans trust this explanation. These views are more common among Evangelicals and Republicans, whereas Black respondents are less inclined to deem this justification valid. Qualitative analyses reveal that those who accept the doctor’s rationale are more likely to acquiesce to doctors’ medical knowledge, to assert that doctors have professional discretion in making referrals, and to reference complications stemming from the patient’s presumed receipt of gender-affirming care despite the routine nature of their sick visit. These findings indicate that doctors’ enduring cultural authority powerfully intersects with “trans exceptionalism” to inform Americans’ perspectives on the denial of care to trans people.
Article
Background Awareness about existing health disparities affecting sexual minorities remains insufficient, and nursing professionals often lack self-awareness about their biases and assumptions concerning lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) individuals. Purpose To explore how exposure to the LGBTQ community, during both classroom and clinical experiences, relates to nursing students’ confidence in providing culturally congruent care to this group. Methods This nonexperimental correlational study occurred at a Midwest 4-year public university, involving final-semester baccalaureate nursing students who completed demographic and educational preparation surveys regarding their confidence in providing health care to the LGBTQ population. Results Results indicate that participants with no direct care experience were more confident in their communication skills and culturally congruent patient care for sexual minorities compared to those exposed to sexual minorities in clinical settings. Conclusions Nursing students’ perceptions and experiences in delivering culturally congruent health care to sexual minorities provide an interesting perspective for examining the Dunning-Kruger effect.
Article
Sexual and gender minorities (SGMs) experience critical barriers to health care access and have unique health care needs that are often overlooked. Given the rise in individuals identifying as lesbian, gay, bisexual, transgender, and queer, colorectal surgeons are likely to care for increasing numbers of such individuals. Here, we discuss key barriers to health care access and research among SGM populations and outline approaches to address these barriers in clinical practice. We also highlight two specific topics relevant to SGM populations that colorectal surgeons should be familiar with: current approaches to anal cancer screening among men who have sex with men, and transgender individuals, as well as the management of recto-neovaginal fistula in transfeminine individuals.
Article
Purpose The aim of this cross‐sectional study was to investigate whether the characteristics of dental schools and the profiles of their deans were associated with curricular activities related to LGBTQ+ in Brazilian dental schools. Methods A survey was mailed to the deans of all Brazilian dental schools for the purpose of assessing the development of pedagogical activities focused on the topic of oral health of the LGBTQ+ population, and the characteristics of the institutions and profiles of their deans. The data collected were analyzed with hierarchical multiple logistic regression models in order to analyze associations between variables of interest. Results Of the deans approached, 156 (response rate of approximately 32.4%) completed and returned the survey. The majority of dental schools (67.3%) of the sample were private institutions and 39% of them developed pedagogical activities directed toward the LGBTQ+. This percentage was much lower in public institutions (18%). The results of the hierarchical multiple logistic regression demonstrated that deans who attributed high relevance to the theme “oral health of the LGBTQ+ population” were more likely to develop pedagogical activities directed toward the LGBTQ+ population (odds ratio = 4.74; 95% confidence interval: 1.65–13.48), than those who attributed low or little importance to this topic ( p < 0.05). Conclusion A low percentage of activities aimed at the LGBTQ+ population was observed in the sample of Brazilian dental schools. Deans must be aware of the importance of the topic and be motivated to implement pedagogical activities for this population.
Article
Sexual and gender minorities (SGMs) have experienced progressive change over the last 50 years. However, this group still reports worse health and health care experiences. An innovative survey instrument that applies stereotype threat to the health care setting, health care stereotype threat (HCST), offers a new avenue to examine these disparities. We harmonized two national probability data sets of SGMs—Generations and TransPop—capturing 503 gay men, 297 lesbians, 467 bisexuals, and 221 trans people. Using these data, we, first, explored how HCST’s association with self-rated health and psychological distress changed while considering more established constructs: discrimination and stigma. Second, we examined how HCST’s association varied across SGM groups. Results suggest that HCST is a unique predictor net of the associations with discrimination and stigma. Furthermore, results highlight the more consequential associations for trans people on well-being compared to gay men. We discuss implications of these findings for future research and potential interventions.
Article
Health care research has long overlooked the intersection of multiple social inequalities. This study examines influenza vaccination inequities at the intersection of sexuality, gender, and race-ethnicity. Using data from the 2013 to 2018 National Health Interview Survey (N = 166,908), the study shows that sexual, gender, and racial-ethnic identities jointly shaped flu vaccination. Specifically, White gay men had the highest vaccination rate (56%), while Black bisexual women had the lowest rate (23%). Across Black, Hispanic, and White individuals, sexual minority women had lower vaccination rates than heterosexual women, but sexual minority men had higher or similar vaccination rates than heterosexual men. Economic enabling, noneconomic enabling, and need-based factors together explained a substantial portion of these gaps. However, they cannot explain all the disadvantages faced by Black lesbian, bisexual, and heterosexual women and Black heterosexual men. Findings offer new evidence of hidden health care inequities and inform health policies from an intersectional perspective.
Article
Full-text available
Background: In the United States, inequities in preventive health behaviors such as cervical cancer screening have been documented. Sexual orientation, gender identity, and race/ethnicity all individually contribute to such disparities. However, little work has investigated their joint impact on screening behavior. Methods: Using sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date cervical cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications. Results: Within all races, individuals who identify as members of sexual and gender minority (SGM) communities reported higher rates of never being screened (except for Black transgender men) than straight or cisgender individuals (p < 0.0001). [*START* Across all races, the Asian/Pacific Islander transgender population (32.4%; weighted n (w.n.) = 1,313) had the lowest proportion of lifetime screening, followed by the Asian/Pacific Islander gay/lesbian (53.0%, w.n. = 21,771), Hispanic transgender (58.7%; w.n. = 24,780), Asian/Pacific Islander bisexual (61.8%, w.n. = 54,524), and Hispanic gay/lesbian (69.6%, w.n. = 125,781) populations. *END*] Straight or cisgender Non-Hispanic White (w.n. = 40,664,476) individuals had the highest proportion of lifetime screening (97.7% and 97.5%, respectively). However, among individuals who had been screened at least once in their lifetime, identifying as SGM was not associated with a decreased proportion of up-to-date screening within or between races. Conclusions: Due to small sample sizes, especially among Asian/Pacific Islander and Hispanic populations, confidence intervals were wide. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed. Impact: These screening disparities reveal the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.
Article
Purpose: We examined the relationship between state context and survey nonresponse to sexual orientation (SO) and gender identity (GI) questions. Methods: We obtained data from the 2014-2020 Behavioral Risk Factor Surveillance System (BRFSS) surveys. Item nonresponse was defined as selecting "don't know/not sure" or "refused" for each of two questions about SO and GI. Nonresponse patterns included responding to both SO and GI questions; responding only to the SO question (nonresponse to GI); responding only to the GI question (nonresponse to SO); and responding to neither question. State-level contextual measures included legal protections for lesbian, gay, bisexual, transgender, or other sexual or gender minority (LGBT+) people, LGBT+ social movement strength, and public opinion regarding LGBT+ issues. Results: The analysis included 1,459,525 respondents from 44 states (190 state-years). On weighted analysis, 96.5% of adults answered both SO/GI questions, 2.4% responded only to GI, 0.4% responded only to SO, and 0.7% responded to neither. The demographic profile of individuals with GI-only nonresponse differed markedly from the profile of adults with SO-only nonresponse. An increasingly favorable legal climate for LGBT+ people was associated with greater rates of response to SO and GI questions. However, a more LGBT+ friendly state climate measured by social movement strength or public opinion was not consistently associated with reduced SO and GI question nonresponse. Conclusion: Contextual factors have mixed association with nonresponse to SO and GI question on BRFSS surveys. Our results warrant continued development of health survey questionnaires to elicit accurate information on respondents' SO and GI.
Article
The Black population in Canada is characterized by its long-established history and diversity. The present study aims to expand our current understanding of the relation between discrimination and disparities in healthcare by including race and language as determinants of health. We recruited 531 Black adults who are currently living in Quebec, Canada, to complete a survey measuring socio-demographic characteristics, mental and physical health, accessibility to healthcare, and experiences of discrimination. Results showed that being a racialized and linguistic minority population in Quebec, English-speaking Black participants experienced more discrimination, fewer healthcare providers, less access to COVID-19 information during the COVID-19 pandemic, and were more dissatisfied with the healthcare system than French-speaking Black participants. Furthermore, the negative impacts of healthcare access associated with being a racialized and linguistic minority population in Quebec (e.g., the English-speaking Black population) were shown to be mediated by experiences of discrimination and dissatisfaction with the healthcare system.
Article
Full-text available
The goal of this exploratory study was to delineate health differences among transgender subpopulations (transgender women/TW, transgender men/TM, gender nonbinary/GNB adults). 2015 Behavioral Risk Factor Surveillance System data were analyzed to compare the health of three groups (TW:N = 369; TM:N = 239; GNB:N = 156). Logistic regression and adjusted odds ratios were used to determine whether health outcomes (fair/poor health, frequent physical and mental unhealthy days, chronic health conditions, and health problems/impairments) are related to group and its interaction with personal characteristics and socioeconomic position. Group was a significant predictor of fair/poor health and frequent mental unhealthy days, revealing significant health differences between the transgender groups. The odds of poor/fair health were approximately 2.5 times higher in TM and GNB adults relative to TW. The odds of frequent mental unhealthy days for TM were approximately 1.5–2 times greater than TW and GNB adults. Among those with health insurance, the odds of fair/poor health for GNB adults was more than 1.5–2 times higher that of TM and TW. Among those without health insurance, TM had over 7 times greater odds of fair/poor health than TW. This study underscores the importance of classifying and examining the health of the transgender population as unique subpopulations, as notable health differences were discovered. TM and GNB adults have significant health concerns, requiring the attention of clinical interventions aimed at promoting health and preventing illness.
Article
Full-text available
Transgender and nonbinary patients have a wide array of experiences when attempting to access healthcare, including discrimination and having to educate providers about trans people. This study examines the mental health factors connected to transgender and nonbinary patients' experience with providers to determine the likelihood of transgender or nonbinary patients receiving respectful care after a provider knows about the patient's gender identity, and patients' experience of having to educate providers about trans people, controlling for sociodemographic factor. Using data from the 2015 United States Trans Survey (N = 27,715), chi-square tests of independence and multivariate logistic regressions were used to explore the odds of transgender or nonbinary individuals having a positive experience with a doctor or healthcare provider. Of the respondents, 24.31% experienced having to educate a provider about trans people when seeking care, and 62.90% experienced a provider knowing they were transgender or nonbinary and treating them with respect. Those experiencing depression and suicidal thoughts were significantly less likely to have had a provider treat them with respect, and significantly more likely to need to educate their providers. Gender, age, disability status, and educational level were significant across both variables; income was significant regarding having to educate a provider. Healthcare providers need ongoing training and education to improve their care of transgender and nonbinary patients, specifically around acknowledging the multiple backgrounds and experiences of such patients, including those related to mental health, gender, race, age, income, educational level, and disability.
Article
Full-text available
Transgender and gender diverse (TGD) individuals face a long-term, multifaceted process if they choose to begin a gender affirmation journey. Decisions to go on hormone therapy and/or have a surgical procedure necessitate the TGD individual to set up an appointment with a health care provider. However, when TGD patients interact with health care practitioners, problems can arise. This article documents and categorizes the types of unmet expectations that are common in the TGD patient–health care provider social dynamic in the Central Great Plains of the United States. Utilizing a community-based participatory research model, qualitative in-depth interviews were conducted with 27 TGD individuals about their health care experiences. From this, the researchers identified four main themes of unmet expectations: probing, gatekeeping, stigmatizing stance, and misgendering/deadnaming. Steps that can be taken by both the health care provider and the TGD individual to have a more successful encounter are discussed.
Article
Full-text available
Background: Non-binary and genderqueer (NBGQ) people are those who do not identify within the gender binary system (male vs. female), not falling exclusively in man/male or woman/female normative categories. A higher proportion of NBGQ people is usually found within young persons. This population is marginalized and, as such, is at risk of stigmatization and of developing negative health outcomes. As literature on the health of NBGQ people is sparse, this study aims at systematically review the limited studies on this field. Methods: The research questions which guided the systematic review were: (1) What are the differences in the health levels between NBGQ and binary transgender (BT) individuals? (2) What are the differences in the health levels between NBGQ and cisgender individuals? (3) Which medical and psychological interventions are most suitable for improving NBGQ health? According to PRISMA guidelines, a systematic search was conducted in PubMed, PsycInfo, Web of Science, and Google Scholar. Results: Eleven studies met the inclusion criteria for the current systematic review. Among them, 9 were focused on the health differences between NBGQ and BT individuals, 4 of the latter and 1 individually were focused on the health differences between NBGQ and cisgender individuals, and 1 was focused on the evaluation of health outcomes related to medical procedures. No studies assessed psychological interventions aimed at improving health in NBGQ individuals. All studies were cross-sectional, did not generally recruit a large sample of NBGQ individuals, and used non-probability sample design. Results related to the difference in health between NBGQ and BT were mixed; indeed, some found a better health status while others a worse one. Results related to the differences in health between NBGQ and cisgender highlighted higher health needs in NBGQ than in BT individuals. The only study analyzing the effects of medical interventions on health found that NBGQ female-assigned at birth individuals improved their quality of life after chest surgery. Conclusions: Although scholars are starting to pay attention to the NBGQ health, research needs to be expanded both in terms of methodology and research contents. Clinical, health-related social policies, and research recommendations in this field are reported.
Research
Full-text available
On June 17th, 2016, researchers at the Williams Institute, along with a steering committee of advisers, convened an international meeting of experts in Amsterdam. The purpose was to consider the current lack of international standards for collecting data about gender minorities in official, large-scale surveys. There were three primary objectives of the meeting: -Develop a network of academics and other experts who study the collection of data about gender minorities -Determine the desirability and feasibility of developing a set of international best practices for the collection of data about gender minorities -Consider what an international best practices model might look like and determine what additional considerations and steps are needed before beginning to develop these best practices
Article
Full-text available
This study leverages multiple measures of gender from a US national online survey (N = 1,508) to better assess how gender is related to self-rated health. In contrast to research linking feminine behaviors with good health and masculine behaviors with poor health, we find that masculinity is associated with better self-rated health for cisgender men, whereas femininity is associated with better self-rated health for cisgender women. The patterns are similar whether we consider self-identification or how people feel others perceive their gender, though reflected appraisals are most strongly associated with health for cisgender women. We also find that people who report they are seen as gender nonconforming report worse health, but only when this perception does not match their gender identification. Our results demonstrate that multiple measures of gender allow researchers to disentangle how health is not only shaped by gender enactments but also shapes perceptions of gender and gender difference.
Article
Full-text available
In this formative qualitative research, we draw upon the concepts of structural vulnerability and structural competency to examine how transgender and gender non-conforming (TGGNC) patients and healthcare personnel experience service delivery in Emergency Departments (EDs), and how this experience can be improved upon. Between October 2016 and June 2017, we undertook 31 semi-structured interviews with TGGNC patients (n = 11) and physicians (n = 6), nurses (n = 7), and non-clinical staff (n = 7) in four community-based EDs in New Mexico. Our iterative coding and analysis process resulted in eight sets of findings: (1) reasons why TGGNC patients seek care from EDs; (2) perceptions about and experiences of TGGNC patients; (3) relevance of gender identity and sex at birth; (4) bureaucracy and communication; (5) spatial considerations; (6) preparing providers and staff to care for TGGNC patients; (7) the lack of resources for structural prescriptions; and (8) respect, humanity, and sameness. Findings suggest that structural issues adversely impact the health and wellbeing of TGGNC patients and service-delivery practices in the ED. We describe study implications for training ED personnel and modifying this practice setting to prevent delayed care and ensure appropriate services for TGGNC patients in need of structurally competent emergency medicine.
Article
Full-text available
This article uses ethnographic methods to explore how transgender people engage the medicalisation of transgender experience in a U.S. context under the purview of the American Psychiatric Association. Building on sociological literature related to medicalisation, this paper argues that the lived experience of medicalisation is a non‐linear, complex process whereby individual engagement with medical authority is both empowering and constraining in the lives of trans people. Inductive qualitative analysis of 158 hours of participant observation and 33 in‐depth interviews with members of a transgender community organisation revealed that transgender individuals (i) reject a medical frame for gender dysphoria, (ii) embrace and stress the importance of gender‐affirming medical technologies for individual identity development and social interaction and (iii) strategically reintroduce medical logics and embrace medical authority in order to facilitate medical and social recognition, validation and acceptance.
Article
Full-text available
Purpose: This study compares the health status of gender nonconforming transgender adults with gender-binary transgender peers (i.e., transgender men and transgender women). Methods: We performed a retrospective analysis of the 2014-2016 Behavioral Risk Factor Surveillance System. Results: After adjustment for sociodemographic characteristics, proxies for healthcare access, health conditions, and health behaviors, gender nonconforming transgender adults were at increased odds, compared with gender-binary transgender peers, of self-reported poor or fair health and self-reported limitation in any way in any activities because of physical, mental, or emotional problems. Conclusions: Gender nonconforming transgender adults experienced worse self-reported health disparities than gender-binary transgender peers.
Article
Full-text available
Purpose: Research on healthcare among gender-diverse populations has largely focused on people who describe their gender in binary terms, either as trans men or trans women. This qualitative study examined the healthcare experiences of young adults who identify as genderqueer or nonbinary (GQ/NB). Methods: Participants (N = 10) were interviewed about experiences seeking and accessing healthcare. All were young adults (ages 23-33) in the San Francisco Bay area who had accessed healthcare at least once in the prior 6 months. A semistructured interview guide elicited conversations about gender identity and experiences of healthcare. Interview transcripts were analyzed using emergent coding analysis to identify themes. Results: Participants faced unique challenges even at clinics specializing in gender-affirming healthcare. They felt misunderstood by providers who approached them from a binary transgender perspective and consequently often did not receive care sensitive to nonbinary identities. In response to this perceived bias, participants sometimes "borrowed" a binary transgender label to receive care, modified the healthcare they were prescribed, or went without healthcare. The GQ/NB young adults in our study regularly felt disrespected and frustrated as they sought and accessed healthcare. Participants felt that the binary transgender narrative pressured them to conform to binary medical narratives throughout healthcare interactions. Conclusions: GQ/NB young adults have unique healthcare needs but often do not feel understood by their providers. There is a need for existing healthcare systems to serve GQ/NB young adults more effectively.
Article
Full-text available
In the past decade, a few countries have created a third gender category to legally recognize gender-nonconforming individuals. However, we know relatively little about the response of the gender-nonconforming individuals toward the legal third gender category. To address this gap, this article analyzes the different social, religious, and institutional discourses that have emerged around the recently created third gender category in Pakistan and their influence on the legal consciousness of the Khawaja Sira community, a marginalized gender-nonconforming group. Even though the third gender category was created to address the unique gender identity of the Khawaja Sira community, most continue to legally register as men. My research indicates that the patriarchal stigma, high compliance costs, and limited material benefits associated with the legal third gender category dissuade the Khawaja Sira community from choosing to register. My findings point to the limitations of a legal third gender category within a patriarchal sociolegal order where important benefits associated with the masculine identity are forfeited by registering. In doing so, my research cautions against over emphasizing the symbolic value of legal recognition for gender-nonconforming groups.
Article
Full-text available
Accumulating evidence suggests that sexual minority individuals are at increased risk for physical health conditions compared to heterosexual individuals. However, we know little about physical health disparities affecting bisexual individuals, a population at increased risk for psychiatric and substance use conditions compared to both heterosexual and lesbian/gay populations. Using a large, nationally representative sample, we examined physical health disparities for bisexual individuals. To advance research on sexual minority health disparities, we further: (1) compared prevalence rates of physical health conditions across three dimensions of sexual orientation (i.e., identity, attractions, behavior) and (2) examined whether disparities differed by sex and race/ethnicity. Results indicated that sexual minority individuals were at increased risk for many physical health conditions. Notably, individuals with bisexual identity, attractions, and/or behavior were at increased risk for more physical health conditions than other sexual minority groups. The number and types of physical health disparities affecting bisexually identified individuals and individuals with same- and opposite-sex attractions and/or sexual partners varied across sex and race/ethnicity, with the most consistent disparities emerging for individuals who reported same- and opposite-sex sexual partners. Our findings highlight the substantial physical health disparities affecting sexual minorities and the heightened risk conferred by all facets of bisexuality.
Article
Full-text available
Gender-affirming care, including hormone therapy, “top” (e.g., chest reconstruction surgery) and “bottom” (e.g., vaginoplasty, phalloplasty, metoidioplasty, etc.) surgeries, and puberty blockers, is an efficacious treatment of gender dysphoria for transgender and gender nonconforming (TGNC) individuals. However, many TGNC people encounter significant barriers in accessing gender-affirming care, which we detail via results from on online study. Participants included 256 TGNC individuals (78.9% White, ages 16–73, Mage = 28.4). Among participants, 61.3% were receiving hormone therapy, 22.7% had undergone top surgery, and 5.5% had undergone bottom surgery. Open-ended responses (n = 201) were thematically analyzed and common barriers included finances and insurance issues, a lack of service availability, and fears or worries. Participants reported various systemic issues and incidents of bias within medical and mental health fields, as well as a lack of medical provider awareness and education. Other themes were interpersonal barriers (e.g., fears of rejection); age and need of parental consent for minors; other medical issues; and a lack of information about how to acquire care. These findings can be utilized to educate professionals in medical and mental health fields about barriers their TGNC patients may encounter in receiving affirming care and suggest a number of ways to improve access to these services.
Article
Full-text available
Many transgender Americans continue to remain uninsured or are underinsured because of payers' refusal to cover medically necessary, gender-affirming healthcare services-such as hormone therapy, mental health counseling, and reconstructive surgeries. Coverage refusal results in higher costs and poor health outcomes among transgender people who cannot access gender-affirming care. Research into the value of health insurance coverage for gender-affirming care for transgender individuals shows that the health benefits far outweigh the costs of insuring transition procedures. Although the Affordable Care Act explicitly protects health insurance for transgender individuals, these laws are being threatened; therefore, this article reviews their importance to transgender-inclusive healthcare coverage.
Article
Full-text available
Background LGBT community organizations in the United States have been providing health services since at least the 1970s. However, available explanations for the origins of LGBT health services do not sufficiently explain why health in particular has been so closely and consistently linked to LGBT activism. Little is also known regarding how LGBT health services may have evolved over time with the growing scientific understanding of LGBT health needs. Methods This study begins with a review of the early intersections of sexuality and health that led to an LGBT health movement in the United States, as well as the evolution of LGBT health services over time. Informed by this, an asset map displaying the location and types of services provided by “LGBT community health centers” today in relation to the population density of LGBT people was explored. An online search of LGBT community health centers was conducted between September–December, 2015. Organizational details, including physical addresses and the services provided, were confirmed via an online database of federally-registered non-profit organizations and organizational websites. The locations and types of services provided were analyzed and presented alongside county-level census data of same-sex households using geographic information system (GIS) software ArcGIS for Desktop. Findings LGBT community health centers are concentrated within urban hubs and coastal states, and are more likely to be present in areas with a high density of same-sex couples. LGBT community health centers do not operate in 13 states. The most common health services provided are wellness programs, HIV/STI services, and counseling services. Conclusions LGBT community health centers have adapted over time to meet the needs of LGBT people. However, significant gaps in service remain in the United States, and LGBT community health centers may require significant transformations going forward in order to continue serving LGBT people.
Article
Full-text available
Health disparities related to stigmatized characteristics, including sexual orientation, have been well-documented. However, it is largely unknown whether temporal declines in stigma at a structural level contribute to concomitant reductions in health disparities between stigmatized and nonstigmatized groups. The objective of this study was to (a) explore associations between reductions in structural stigma (i.e., laws, policies, and social attitudes concerning sexual minorities) during the past decade in Sweden and sexual orientation-based mental health disparities, and (b) identify potential mechanisms that might explain this relationship. Repeated nationwide population-based cross-sectional surveys in 2005, 2010, and 2015 were conducted among individuals (16–84 years of age) in Sweden (N = 23,248 individuals, 565 self-identified as lesbian, gay, or bisexual). The interaction between structural stigma and sexual orientation was statistically significant, demonstrating a stronger reduction over 10 years in psychological distress (Wald χ2 = 6.03; p = .01) and in victimization/threat of violence (Wald χ2 = 7.00; p
Article
Full-text available
This research investigates transgender individuals’ experiences with misgendering—the misclassification of gender identity—from a minority stress perspective. Four hundred and ten transgender individuals (M = 30.27 years, 83.9% European American) participated in a survey in which they reported how frequently they are misgendered and how stigmatized they feel when it occurs in addition to protective factors (gender identity importance, social support) and psychological distress (anxiety, depression, stress, transgender felt stigma). On average, participants reported being misgendered sometimes (M = 3.05, SD = 1.18) and feeling somewhat stigmatized by these experiences (M = 3.64, SD = 1.30). Perceived frequency of misgendering and feeling stigmatized by these experiences were positively associated with identity importance, but only perceived frequency was negatively associated with social support. Both perceived frequency and feeling stigmatized were positively associated with psychological distress. In turn, identity importance and social support were positively associated with psychological distress. There was a significant interaction between felt stigma and identity importance in predicting depression and stress. There was a positive association between felt stigma and stress and depression at low and high levels of identity importance, but this association was stronger at low levels of identity importance. In addition, there was a significant interaction between perceived frequency of misgendering and social support such that the association between perceived frequency and felt stigma was positive at low levels of social support but not at high levels of social support. In conclusion, misgendering is likely a novel minority stressor for transgender people.
Book
Full-text available
Ozzie and Harriet, move over. A new couple is moving into the neighborhood. In the postmodern era, advances in medical technologies allow some individuals categorized female at birth to live in accordance with their gender identities, as men. While a growing body of literature on transgender men's experiences has come to the forefront, relatively little exists to document the experiences of their partners. In Queering Families: The Postmodern Partnerships of Cisgender Women and Transgender Men, Carla A. Pfeffer brings these experiences to light through interviews with the group most likely to partner and form families with transgender men: non-transgender (cisgender) women. Drawing upon in-depth interviews with fifty cisgender women partners of transgender men from across the United States and Canada, Pfeffer details the experiences of a community that often seems unremarkable and ordinary on its surface. Cisgender women who partner with transgender men who are socially "read" as male are often (mis)perceived as part of a heterosexual couple or family. Yet not all cisgender women who partner with transgender men are comfortable with this invisible existence and comfortable normativity. Instead, many of the cisgender women Pfeffer interviews hold deeply-valued queer identities that may be erased in their partnerships with transgender men. Queering Families details the struggles and strengths of these postmodern "Harriets" as they work to build identities, partnerships, families, and communities. Pfeffer's interviewees discuss the implications of visibility and invisibilty in their everyday lives as they face barriers or pathways to legal and social inclusion. They carve out new lexicons for partners' bodies and their own sexualities, transformed through gender-affirming hormones and surgeries. They plan and construct families with and without children, some drawing upon alternative reproductive technologies to bear the biological offspring of their transgender partners. With remarkable depth and insight, Queering Families explores a shifting social landscape that challenges the very notion of what constitutes a "same-sex" or an "opposite-sex" relationship, marriage, or family.
Article
This article employs the gender‐as‐relational (GAR) approach to enhance the study of the long‐term romantic relationships of sexual and gender minority mid‐ to later‐life adults. The GAR approach states that gender in relationships is shaped by three key factors: own gender, partner gender, and the gendered relational context. This approach emphasizes that the relationship dynamics of men, women, and gender‐nonconforming individuals are highly diverse, reflecting that gender is a social construct formed within interactions and institutions. We explicate how GAR can reorganize the study of sexual and gender diversity in three research areas related to aging and relationships—caregiving, marital health benefits, and intimacy—and discuss theory‐driven methods appropriate for a GAR research agenda. A GAR framework reorients research by complicating taken‐for‐granted assumptions about how gender operates in mid‐ to later‐life romantic relationships and queering understandings of aging and romantic relationships to include experiences outside of heteronormative and cisnormative categories.
Article
Objective This is the first national study to examine disparities in loneliness and social relationships by sexual orientation in late adulthood in the United States. Background Prior studies have shown that lesbian, gay, and bisexual (LGB) individuals often struggle with social relationships across the life course, likely because of stigma related to sexual orientation. However, little is known about whether loneliness is more prevalent among LGB people than among other groups in late adulthood, and if so, which relationships contribute to the loneliness gap. Method We analyzed data from a nationally representative sample of older adults from the 2015–2016 National Social Life, Health, and Aging Project (N = 3,567) to examine the disparity in loneliness by sexual orientation and identify links between this disparity and multiple dimensions of social relationships, including partner, family, friend, and community relationships. Results Older LGB adults were significantly lonelier than their heterosexual counterparts, primarily due to a lower likelihood of having a partner and, to a lesser extent, lower levels of family support and greater friend strain. While they were also disadvantaged in the size of close family and frequency of community participation, these factors were less relevant to their loneliness. Overall, the conventionally defined inner layers of relationships (partnership and family) contributed more to the loneliness disparity than the outer layers of relationships (friends and community). Conclusion These findings suggest that strengthening the partnerships and family relationships of sexual minorities is essential to reducing the loneliness gap.
Article
Background and objectives: Gonadotropin-releasing hormone analogues are commonly prescribed to suppress endogenous puberty for transgender adolescents. There are limited data regarding the mental health benefits of this treatment. Our objective for this study was to examine associations between access to pubertal suppression during adolescence and adult mental health outcomes. Methods: Using a cross-sectional survey of 20 619 transgender adults aged 18 to 36 years, we examined self-reported history of pubertal suppression during adolescence. Using multivariable logistic regression, we examined associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality. Results: Of the sample, 16.9% reported that they ever wanted pubertal suppression as part of their gender-related care. Their mean age was 23.4 years, and 45.2% were assigned male sex at birth. Of them, 2.5% received pubertal suppression. After adjustment for demographic variables and level of family support for gender identity, those who received treatment with pubertal suppression, when compared with those who wanted pubertal suppression but did not receive it, had lower odds of lifetime suicidal ideation (adjusted odds ratio = 0.3; 95% confidence interval = 0.2-0.6). Conclusions: This is the first study in which associations between access to pubertal suppression and suicidality are examined. There is a significant inverse association between treatment with pubertal suppression during adolescence and lifetime suicidal ideation among transgender adults who ever wanted this treatment. These results align with past literature, suggesting that pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes.
Article
We investigate whether the subjective well-being of individuals in same-sex unions improved following the legalization of same-sex marriage in England and Wales in March 2014. We employ repeated cross-sectional data from the 2011–2016 Annual Population Surveys on 476,411 persons, including 4,112 individuals in coresidential same-sex relationships. The analysis reveals increases in subjective well-being for individuals in same-sex relationships following legalization. Additional analysis documents higher subjective well-being for individuals in married same-sex couples compared with individuals who are in a civil partnership or an informal cohabiting same-sex union. However, the subjective well-being of individuals from same-sex couples increased after legalization among all subgroups considered, including those who cohabited informally. This result hints at a general reduction in structural stigma as an important mechanism behind the improved well-being of individuals in same-sex unions.
Article
It has long been documented that married individuals have better health outcomes than unmarried individuals. However, this marital advantage paradigm has been developed primarily based on heterosexual populations. No studies to date have examined the health effects of marriage among bisexuals, one of the most disadvantaged but understudied sexual minority groups, although a few have shown mixed results for gays and lesbians. Similarly, no research has examined how the gender composition of a couple may shape bisexuals’ health outcomes above and beyond the effects of sexual orientation. We analyzed pooled data from the 2013–2017 National Health Interview Survey (n = 154,485) and found that the health advantage of marriage applied only to heterosexuals and, to a lesser extent, gays and lesbians. Married bisexuals, however, exhibited poorer health than unmarried bisexuals when socioeconomic status and health behaviors were adjusted for. Moreover, bisexuals in same-gender unions were healthier than bisexuals in different-gender unions primarily because of their socioeconomic advantages and healthier behaviors. Together, our findings suggest that bisexuals, particularly those in different-gender unions, face unique challenges in their relationships that may reduce the health advantage associated with marriage.
Article
Using updated data from the General Social Survey/National Death Index (GSS/NDI) study, we examined whether the relationship between structural stigma-measured by aggregating 4 items assessing prejudice towards homosexuality to the community level-and all-cause mortality is present among gay men/lesbian women. Our hypothesis is based on emerging evidence that indicators of structural stigma specific to homosexuality, such as those used in the GSS/NDI, uniquely predict health outcomes among this group. Because the GSS/NDI lacked an identity-based measure of sexual orientation, we tested our hypothesis by employing a strategy that has a relatively high degree of sensitivity and specificity for ascertaining individuals most likely to identify as gay or lesbian: restricting analyses to individuals who reported same-sex sexual partners in the past year. We compared this approach against an alternative strategy, which has weaker specificity for identifying gay men/lesbian women: restricting analyses to individuals who reported any lifetime same-sex sexual behaviors. After controlling for 6 individual-level factors and fixed effects of survey year, structural stigma was associated with mortality among individuals who reported past-year same-sex sexual partners (HR = 1.95, 95% CI: 1.14, 3.31). Further, there was a dose-response relationship with mortality in this group, such that those residing in communities in the highest quartile of structural stigma had the greatest mortality risk, controlling for these same factors (HR = 2.12, 95% CI: 1.03, 4.38). In sensitivity analyses, the effect size for structural stigma ranged from 1.54 to 2.30, indicating a consistent, but small-to-moderate, effect. In contrast, no association between structural stigma and mortality was observed among respondents who reported lifetime same-sex sexual partners, nor among those reporting only opposite-sex sexual partners. This analysis therefore delimits potential boundary conditions of the association between structural stigma related to same-sex sexuality and all-cause mortality, highlighting the conditions under which this association is (and is not) observed.
Article
This commentary explores how different types of insurance (Medicare, Medicaid, state government, and private insurance) address issues of transgender-related care, and how access to transgender affirming insurance coverage and healthcare across life stages depends both on type of insurance and geographical location. We argue that the current state of transgender health insurance policy and practices are inadequate for achieving goals of continuity of care and positive health outcomes across the life course. Transgender individuals are uninsured at a higher rate than their cisgender (non-transgender) counterparts, face discrimination or refusal of care from their providers, and, if insured, experience denials of coverage from insurance companies. These ruptures in coverage can be addressed through extending insurance coverage for all treatments necessary to affirm a transgender person's gender identity, training to support transgender affirming healthcare, and research on the health needs of the transgender community across the life course.
Article
Binary gender and sexuality are socially constructed, but they structure thought at such a deep level that even those critical of sexism and homophobia can unwittingly reproduce them, with consequences felt most profoundly by those whose gender/sexual identity defy binary logic. This article outlines a generic pattern in the reproduction of inequality we call foreclosing fluidity, the symbolic or material removal of fluid possibilities from sexual and gender experience and categorization. Based on 115 responses from people who are both sexually and gender fluid and a reading of existing sociologies of gender and sexualities from a fluid standpoint, we demonstrate how lesbian/gay/straight, cisgender, and transgender women and men—regardless of intentions—may foreclose fluidity by mobilizing cisnormative, transnormative, heteronormative, and/or homonormative beliefs and practices. Examining patterns of foreclosing fluidity may provide insight into (1) the further incorporation of fluid people and standpoints into symbolic interactionism, and (2) the reproduction and persistence of sexual and gender inequalities.
Article
Using in-depth interviews with 23 physical and mental healthcare providers and observations at transgender-specific healthcare conferences between 2012 and 2015, I examine how medical providers negotiate informed consent processes in their clinical encounters with trans patients. While a growing body of scholarship has examined informed consent in scientific research from the patient's perspective, a gap remains in how informed consent is understood in clinical encounters, and from providers’ perspectives. I use the case of trans medicine, an emergent field of medicine that has not yet implemented standardized procedures or policies that shape providers’ decision-making. I demonstrate how many providers of trans medicine give voice to following informed consent, but fail to actually practice it in their work with trans patients. In performing informed consent, providers revert to a paternalistic model of care, which amplifies their medical authority while veiling power differentials in their clinical encounters and decision-making in trans medicine.
Article
In their attempt to address racial disparities in the provision of health care, the U.S. medical profession has reproduced racial inequalities of their own. In this article, I draw upon interview data with medical educators and students to detail how medical educators routinely offload the instruction on the social underpinnings and consequences of race onto students, particularly students of color. I develop the concept of the conscripted curriculum to capture how students’ social identities are utilized by educators in the professionalization process. While there are exceptions in curricular approaches, most educators create the conscripted curriculum by eliciting students to share their social experiences with race in the small group setting while only providing students with didactic material on biological understandings of race. As a result, students of color report experiencing more emotionally exhausting and unrewarded labor than their white peers, and educators further devalue the social implications of race for health care.
Article
Background: Transgender individuals are more likely to experience social and economic barriers to health and health care, and have worse mental health outcomes than cisgender individuals. Our study explores variations in mental health among minority genders after controlling for sociodemographic factors. Materials and methods: Multistate data were obtained from the 2014 to 2016 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. Data were included from respondents who were asked whether they identified as transgender, and if so, as male-to-female (MTF), female-to-male (FTM), or gender nonconforming. Frequent mental distress (≥14 days in the last month of "not good" mental health) was the primary outcome of interest. Analysis was performed using design-adjusted Chi-square tests and multivariable logistic regression models of frequent mental distress with gender identity as the independent variable of interest. Results: Of 518,986 respondents, 0.51% identified as transgender. Higher rates of frequent mental distress were found between FTM (24.7% [18.5-32.3]) and gender nonconforming populations (25.4% [18.7-33.5]), compared with the MTF population (14.2% [10.9-18.3]). After controlling for sociodemographic factors, non-transgender female (adjusted odds ratio [aOR] 1.39 [confidence interval, CI 1.32-1.46]), FTM (aOR 1.93 [CI 1.26-2.95]), and gender nonconforming (aOR 2.05 [CI 1.20-3.50]) identities were associated with increased odds of frequent mental distress compared with non-transgender males. Conclusions: Our findings suggest differences in the mental health of transgender and non-transgender individuals, and between gender minorities within transgender population. The differences persist after controlling for sociodemographic factors. Our results suggest that considering the spectrum of minority genders within the transgender population may be important in understanding health outcomes.
Article
Marriage benefits health in part because spouses promote one another's well-being, yet how spouses facilitate formal health care (e.g., doctor's visits, emergency care) via what we call health care work is unknown. Moreover, like other aspects of the marital-health link, health care work dynamics likely vary by gender and couple type. To explore this possibility, we use in-depth interviews with 90 midlife gay, lesbian, and heterosexual spouses to examine how spouses perform health care work. Our results show that in heterosexual marriage, women perform the bulk of health care work and typically do so in coercive ways. A minority of heterosexual men provide instrumental health care work for their wives. Gay and lesbian spouses appear to commonly use both coercive and supportive health care work strategies to effectively promote health care use. Our findings demonstrate the ways spouses are central to supporting and coercing one another to obtain medical care and how these patterns are gendered.
Article
Looking beyond binary measurements of "male" or "female" can illuminate health inequality patterns that correspond to gender identity rather than biological sex. This study examines disparities in overall health among transgender men, transgender women, gender-nonconforming adults, and cisgender (nontransgender) men and women in the U.S. Population: Behavioral Risk Factor Surveillance System (BRFSS) data from 32 U.S. states and territories between 2014 and 2016 yield an analytic sample that identifies 2,229 transgender and gender-nonconforming adults and 516,753 cisgender adults. Estimates from logistic regression models, using cisgender men as a reference group, show that gender-nonconforming respondents have significantly higher odds of reporting poor self-rated health than any other gender identity group. Transgender men also display higher odds of reporting poor health in some models, corresponding to their relative socioeconomic disadvantage. I find no apparent health disadvantage among transgender women and a persistent, if slight, disadvantage among cisgender women. Gender-nonconforming respondents' predicted probabilities of reporting poor health remain nearly twice as high as those of cisgender men after adjustments for demographic, socioeconomic, and behavioral factors. Their persistent patterns of health-related disadvantage underscore the need for higher-quality data on gender-nonconforming respondents that account for sex assigned at birth.
Book
Trans Kids is a trenchant ethnographic and interview-based study of the first generation of families affirming and facilitating gender nonconformity in children. Earlier generations of parents sent such children for psychiatric treatment aimed at a cure, but today, many parents agree to call their children new names, allow them to wear whatever clothing they choose, and approach the state to alter the gender designation on their passports and birth certificates. Drawing from sociology, philosophy, psychology, and sexuality studies, sociologist Tey Meadow depicts the intricate social processes that shape gender acquisition. Where once atypical gender expression was considered a failure of gender, now it is a form of gender. Engaging and rigorously argued, Trans Kids underscores the centrality of ever more particular configurations of gender in both our physical and psychological lives, and the increasing embeddedness of personal identities in social institutions.
Article
Prior research based on studies of heterosexual populations suggests that men’s health benefits more from marriage than women’s, in part because women do more than men to influence the health habits of their spouse. We extend this work by using dyadic survey data from 838 spouses in 419 gay, lesbian, and heterosexual marriages to consider differences in social control tactics across same-sex and different-sex couples—that is, how spouses monitor and regulate each other’s health habits. Results suggest that although gender differences in social control are common, gendered patterns sometimes differ depending on whether one is in a same-sex or different-sex marriage. Results also point to the importance of health habits as strong drivers of relationship dynamics across gay and lesbian as well as heterosexual marriages.
Article
Among LGBTQ people, those who are gender nonconforming (GNC) may be at heightened risk of both discrimination and underutilization of healthcare—yet little is known about what happens during healthcare encounters to compel GNC individuals to continue or avoid seeking future care. This study qualitatively examines the healthcare experiences of a racially diverse sample of 34 adult LGBTQ cis women, transgender men, and nonbinary individuals in a metropolitan area of the United States who do not conform to dominant biomedical schemas of sex and gender. GNC individuals experience embodied disruption in medical settings when patients are mis/recognized; providers respond to disruption in ways that further distress patients. Broadly, participants report similar experiences across racial and gender identities, but patients manage disruption somewhat differently depending on their embodied positions to gender norms. This study contributes to literature of stress, stigma, and sex, gender, and sexuality within medicine by illuminating how stigmatizing healthcare interactions deter LGBTQ individuals from seeking healthcare. Findings point to the importance of considering both structural factors and embodied visibility in future research addressing how stigma and discrimination manifest within health settings to disadvantage LGBTQ groups.
Article
Context: Very little population-based research has examined health and access to care among transgender populations. This study compared barriers to care between cisgender, transgender, and gender nonconforming (GNC) adults using data from a large, multistate sample. Methods: We used data from the 2014-2015 Behavioral Risk Factor Surveillance System to estimate the prevalence of having no health insurance, unmet medical care needs due to cost, no routine checkup, and no usual source of care for cisgender women (n = 183,370), cisgender men (n = 131,080), transgender women (n = 724), transgender men (n = 449), and GNC adults (n = 270). Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for each barrier to care while adjusting for sociodemographic characteristics. Findings: Transgender and GNC adults were more likely to be nonwhite, sexual minority, and socioeconomically disadvantaged compared to cisgender adults. After controlling for sociodemographic characteristics, transgender women were more likely to have no health insurance (OR = 1.60; 95% CI = 1.07-2.40) compared to cisgender women; transgender men were more likely to have no health insurance (OR = 2.02; 95% CI = 1.25-3.25) and no usual source of care (OR = 1.84; 95% CI = 1.18-2.88); and GNC adults were more likely to have unmet medical care needs due to cost (OR = 1.93; 95% CI = 1.02-3.67) and no routine checkup in the prior year (OR = 2.41; 95% CI = 1.41-4.12). Conclusions: Transgender and GNC adults face barriers to health care that may be due to a variety of reasons, including discrimination in health care, health insurance policies, employment, and public policy or lack of awareness among health care providers on transgender-related health issues.
Article
Previous studies suggest that members of sexual minority groups have poorer access to health services than heterosexuals. However, few studies have examined how sexual orientation interacts with gender and race to affect health care experience. Moreover, little is known about the role in health care disparities played by economic strains such as unemployment and poverty, which may result from prejudice and discrimination based on sexual orientation. Using data for 2013-15 from the National Health Interview Survey, we found that most members of sexual minority groups no longer have higher uninsurance rates than heterosexuals, but many continue to experience poorer access to high-quality care. Gay nonwhite men, bisexual white women, and bisexual and lesbian nonwhite women are disadvantaged in multiple aspects of access, compared to straight white men. Only some of these disparities are attributable to economic factors, which implies that noneconomic barriers to care are substantial. Our results suggest that the intersection of multiple social identities can reveal important gaps in health care experience. Making culturally sensitive services available may be key to closing the gaps. © 2017 Project HOPE-The People-to-People Health Foundation, Inc.
Article
Background: Little research has compared the mental health and victimization experiences of non-binary youth depending on their sex assigned at birth (SAAB), or compared these two groups with binary transgender youth. Aims: To compare mental health, self-harm and suicidality, substance use and victimization experiences between non-binary and binary transgender young adults, both male assigned at birth (MAAB) and female assigned at birth (FAAB). Methods: Online survey data from 677 participants from the “Youth Chances” community study of 16 to 25 year olds in the United Kingdom was analyzed, comparing across binary participants (transgender females (n = 105) and transgender males (n = 210)) and non-binary participants (MAAB (n = 93) and FAAB (n = 269)). Results: Female SAAB participants (binary and non-binary) were more likely to report a current mental health condition and history of self-harm than male SAAB participants (binary and non-binary). Similarly, female SAAB participants (binary and non-binary) were more likely to report childhood sexual abuse than male SAAB participants (binary and non-binary); the reverse pattern was found for lifetime physical assault relating to being LGBTQ. Non-binary MAAB participants were less likely than the other groups to report past suicide attempts and previous help-seeking for depression/anxiety. Binary participants reported lower life satisfaction than non-binary participants. For all four groups, mental health problems, self-harm, suicidality, alcohol use and victimization experiences were generally higher than that of youth in general population studies. Conclusions: These findings highlight the importance of considering both non-binary versus binary gender identity and SAAB in relation to mental health problems, self-harm, suicidality and substance use in transgender youth. The roles of sexual abuse, other abuse and discrimination in contributing to increased rates of mental illness and self-harm in non-binary and binary transgender individuals, particularly those who were assigned female at birth, relative to those assigned male, require investigation.
Article
The field of transgender studies has grown exponentially in sociology over the last decade. In this review, we track the development of this field through a critical overview of the sociological scholarship from the last 50 years. We identify two major paradigms that have characterized this research: A focus on gender deviance (1960s-1990s) and a focus on gender difference (1990s-present). We then examine three major areas of study that represent the current state of the field: Research that explores the diversity of transgender people's identities and social locations, research that examines transgender people's experiences within institutional and organizational contexts, and research that presents quantitative approaches to transgender people's identities and experiences. We conclude with an agenda for future areas of inquiry.
Article
According to the National Transgender Discrimination Survey, 28% of trans respondents reported postponing medical care due to discrimination, and 28% reported being harassed by providers when they did seek out care. Scholars have proposed that what is taught (or not) in medical schools might play a role in the unequal health care experienced by many trans people. As medical education becomes a site of intervention for reducing transgender health disparities, it presents opportunities for sociologists to study and explain the processes by which medical training creates, reinforces, and potentially challenges stigma-related health disparities. In this paper, we propose three areas of inquiry that might help explain this situation: the hidden curriculum, patient health movements and consumerism, and medical competency. By employing these concepts, we argue that sociologists can develop more comprehensive explanations for the relationship between medical education and transgender health inequalities and offer solutions to address this disparity.
Article
The inclusion of same-sex married couples can illuminate and challenge assumptions about gender that are routinely taken for granted in studies of physical illness. We analyze gender dynamics in gay, lesbian, and heterosexual marriages with in-depth interview data from 90 spouses (45 couples) to consider how spouses co-construct illness experiences in ways that shape relationship dynamics. Overall, findings indicate that men tend to downplay illness and thus provide minimal care work, whereas women tend to construct illness as immersive and involving intensive care work—in both same-sex and different-sex marriages. Yet same-sex spouses describe similar constructions of illness much more so than different-sex couples, and as such, same-sex spouses describe less illness-related disagreement and stress. These findings help inform policies to support the health of gay and lesbian, as well as heterosexual, patients and their spouses, an important goal given health disparities of gay and lesbian populations.
Article
To alleviate uncertainty in the specialized field of transgender medicine, mental and physical healthcare providers have introduced the rhetoric of evidence-based medicine (EBM) in clinical guidelines to help inform medical decision making. However there are no diagnostic tests to assess the effectiveness of transgender medical interventions and no scientific evidence to support the guidelines. Using in-depth interviews with a purposive sample of 23 healthcare providers, I found that providers invoked two strategies for negotiating the guidelines. Some used the rhetoric of EBM and closely followed clinical guidelines to contain uncertainty. Others flexibly interpreted the guidelines to embrace uncertainty. These findings raise questions about the effectiveness of EBM and guidelines in medical decision making. While trans medicine involves an identity and not a biomedical illness, providers use the same strategies to respond to uncertainty as they may in other medical arenas.
Article
Countervailing powers constrain the authority and autonomy of the medical profession. One countervailing power is patient consumerism, a movement with roots in health social movements. Patient empowerment discourses that emerge from health social movements suggest that active patienthood is a normative good, and that patients should inform themselves, claim their expertise, and participate in their care. Yet, little is known about how patient empowerment is understood by physicians. Drawing on ethnographic fieldwork in an American medical school, this article examines how physicians teach medical students to carry out patient encounters while adhering to American cultural expectations of a collaborative physician–patient relationship. Overt medical paternalism is characterised by professors as ‘here's the orders’ paternalism, and shown to be counterproductive to ‘closing the deal’ – achieving patient agreement to a course of treatment. To explain how physicians accomplish their therapeutic goals without violating cultural mandates of patient empowerment I develop the concept of ‘constrained collaboration’. This analysis of constrained collaboration contrasts with structural-level narratives of diminishing professional authority and contributes to a theory of the micro-level reproduction of medical authority as a set of interactional practices.