Comparing Two-Step Approaches to Measuring Gender Identity: The Reliability and Applications of Asking About Sex Assigned at Birth versus Transgender Self-Identification.

Inclusive measures of gender are critical for health equity research. This study compared the reliability and applications of two different approaches for measuring gender in response to emerging community concerns regarding the potential harms of asking about sex assigned at birth (SAAB) within transgender and gender diverse (TGD) populations. Using data from a 2021 survey of LGBTQ+ people in Washington state, we compared approaches for measuring gender via a two-step question that collected data on: (1) current gender and SAAB versus (2) current gender and transgender self-identification. Among 2,275 LGBTQ+ participants aged 9-81, 63% were cisgender, 35% TGD, and 2% were not categorized. There was near perfect agreement between the two methods in their ability to identify TGD participants (percent agreement=99.7%, unweighted Cohen's Kappa=0.99). Among gender diverse participants, stratification by SAAB revealed differences in sexual health outcomes, while stratification by transgender self-identification revealed differences in access to gender-affirming care and lifetime experiences of discrimination. Ascertaining SAAB may be most useful for identifying sexual health disparities while transgender self-identification may better illuminate healthcare needs and social determinants of health among TGD people. Researchers and public health practitioners should critically consider the acceptability and relevance of SAAB questions to their research goals.

A Latent Profile Analysis of Religious Parents' Responses to Their Sexual and Gender Diverse Child.

Prior research indicates that religious parents can have negative, positive, or ambivalent responses to their child's sexual orientation and gender identity (SOGI). Yet, to our knowledge no research has quantitatively examined patterns of sexual and gender diverse (SGD) youth's perceptions of their religious parents' responses to their SOGI. Without examining variations in these patterns, we are unable to better understand the experiences of SGD youth with religious parents. In the current paper, we examined patterns of SGD youth's perceptions of their religious parents' SOGI-specific rejection, acceptance, and SOGI change efforts. We also examined if these patterns differed by SGD youth's individual and contextual factors. The analytic sample consisted of online responses from 5,686 SGD youth (Mage = 15.95). We found four distinct profiles: Positive Parental Response, Moderate Negative Parental Response, Low Parental Response, and High Negative Parental Response. The largest profile was the Positive Parental Response, suggesting that many SGD youth perceived positive responses from their religious parents. SGD youth with diverse gender identities and intersecting identities, such as race/ethnicity, were more vulnerable to religious parents' negative responses. Findings have implications for existing resources and programs aimed at strengthening SGD youth's relationship with their religious parents.

University Student Attitudes Regarding Answering Sex, Sexual Orientation, and Gender Identity Questions on University Application Forms.

A sample of 700 undergraduate university students throughout the US completed an online survey about their attitudes answering questions about their sex, sexual orientation, and gender identity (SSOGI) on their university admission form. This study examined differences between cisgender and transgender and gender diverse students in attitudes related to answering sex assigned at birth and gender identity questions, and between heterosexual students and students of diverse sexual orientations in attitudes related to answering sexual orientation questions. Overall, students indicated positive attitudes about answering SSOGI questions on their university application form, but attitudes toward sexual orientation questions were less positive. Differences were found in question/answer choice understanding (gender identity and sexual orientation), ease of answering (sex assigned at birth), offensiveness in asking (sex assigned at birth), privacy concerns (sex assigned at birth), comfort in answering (sex assigned at birth and sexual orientation), confidentiality concerns (gender identity), and importance of asking (sex assigned at birth and sexual orientation). Findings demonstrate that most respondents held positive attitudes about answering SSOGI questions and that communicating to LGBTQ+ applicants the importance of and privacy protections associated with answering SSOGI questions on university application forms might be important.

Patient comfort with sexual orientation and gender identity questions in adult congenital cardiology clinics.

BACKGROUND: Lack of sexual orientation and gender identity (SOGI) data creates barriers for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people in health care. Barriers to SOGI data collection include physician misperception that patients do not want to answer these questions and discomfort asking SOGI questions. This study aimed to assess patient comfort towards SOGI questions across five quaternary care adult congenital heart disease (ACHD) centres. METHODS: A survey administered to ACHD patients (≥18 years) asked (1) two-step gender identity and birth sex, (2) acceptance of SOGI data, and (3) the importance for ACHD physicians to know SOGI data. Chi-square tests were used to analyse differences among demographic groups and logistic regression modelled agreement with statement of patient disclosure of SOGI improving patient-physician communication. RESULTS: Among 322 ACHD patients, 82% identified as heterosexual and 16% identified as LGBTQ+, across the age ranges 18-29 years (39.4%), 30-49 years (47.8%), 50-64 years (8.7%), and > 65 years (4.0%). Respondents (90.4%) felt comfortable answering SOGI questions. Respondents with bachelor's/higher education were more likely to "agree" that disclosure of SOGI improves patient-physician communication compared to those with less than bachelor's education (OR = 2.45; 95% CI 1.41, 4.25; p = .0015). CONCLUSION: These findings suggest that in this largely heterosexual population, SOGI data collection is unlikely to cause patient discomfort. Respondents with higher education were twice as likely to agree that SOGI disclosure improves patient-physician communication. The inclusion of SOGI data in future studies will provide larger samples of underrepresented minorities (e.g. LGBTQ+ population), thereby reducing healthcare disparities within the field of cardiovascular research.

Challenges in collecting information on sexual orientation and gender identity for cancer patients: perspectives of hospital and central cancer registry abstractors.

PURPOSE: Sexual and gender minority (SGM) populations experience cancer treatment and survival disparities; however, inconsistent sexual orientation and gender identity (SOGI) data collection within clinical settings and the cancer surveillance system precludes population-based research toward health equity for this population. This qualitative study examined how hospital and central registry abstractors receive and interact with SOGI information and the challenges that they face in doing so. METHODS: We conducted semi-structured interviews with 18 abstractors at five Surveillance, Epidemiology, and End Results (SEER) registries, as well as seven abstractors from commission on cancer (CoC)-accredited hospital programs in Iowa. Interviews were transcribed, cleaned, and coded using a combination of a priori and emergent codes. These codes were then used to conduct a descriptive analysis and to identify domains across the interviews. RESULTS: Interviews revealed that abstractors had difficulty locating SOGI information in the medical record: this information was largely never recorded, and when included, was inconsistently/not uniformly located in the medical record. On occasion, abstractors reported situational recording of SOGI information when relevant to the patient's cancer diagnosis. Abstractors further noticed that, where reported, the source of SOGI information (i.e., patient, physician) is largely unknown. CONCLUSION: Efforts are needed to ensure standardized implementation of the collection of SOGI variables within the clinical setting, such that this information can be collected by the central cancer registry system to support population-based equity research addressing LGBTQ + disparities.

Characteristics and Consequences of Violent Victimization in Sexual and Gender Minority Communities: An Analysis of the 2017-2021 National Crime Victimization Survey.

Purpose: This article investigates rates of violent victimization, subsequent help-seeking, and health-related consequences within sexual and gender minority (SGM) communities. Methods: Aggregate data from the 2017-2021 National Crime Victimization Survey were examined to determine nationally representative estimates of rates and distributions of violent victimization, help-seeking, and socioemotional consequences within those 16 years of age and older. Due to sample size, most analyses aggregated sexual orientation and gender identity to allow comparison of SGM persons to non-SGM persons and examine differences within the SGM population. Results: Persons who identified as lesbian, gay, or bisexual experienced violent victimization at rates two to six times higher than straight persons. Transgender persons were victimized more than three times as often than cisgender persons. SGM persons experienced higher rates of all types of violent victimization than non-SGM persons regardless of victim-offender relationship. There were differences by victim demographic characteristics, including sex, race and Hispanic origin, age, marital status, and household income. A higher proportion of SGM victims reported only problems with work/school or problems both at work/school and with family/friends. Finally, higher proportions of SGM victims reported socioemotional consequences when they were female, older, or experienced serious violent crime. Conclusion: The findings in this study continue to highlight high levels of violence experienced by SGM persons and disproportionate socioemotional consequences. There is an evident need to develop targeted interventions and provide services to address the consequences of victimization among this population. The analyses demonstrate the necessity of continued research to better understand the impact of violence on SGM communities.

LGBTQ+ cancer: priority or lip service? A qualitative content analysis of LGBTQ+ considerations in U.S. state, jurisdiction, and tribal comprehensive cancer control plans.

The National Comprehensive Cancer Control Program, a Centers for Disease Control and Prevention funded program, supports cancer coalitions across the United States (US) in efforts to prevent and control cancer including development of comprehensive cancer control (CCC) plans. CCC plans often focus health equity within their priorities, but it is unclear to what extent lesbian, gay, bisexual, transgender, queer/questioning, plus (LGBTQ+) populations are considered in CCC plans. We qualitatively examined to what extent LGBTQ+ populations were referenced in 64 U.S. state, jurisdiction, tribes, and tribal organization CCC plans. A total of 55% of CCC plans mentioned LGBTQ+ populations, however, only one in three CCC plans mentioned any kind of LGBTQ+ inequity or LGBTQ+ specific recommendations. Even fewer plans included mention of LGBTQ+ specific resources, organizations, or citations. At the same time almost three fourths of plans conflated sex and gender throughout their CCC plans. The findings of this study highlight the lack of prioritization of LGBTQ+ populations in CCC plans broadly while highlighting exemplar plans that can serve as a roadmap to more inclusive future CCC plans. Comprehensive cancer control plans can serve as a key policy and advocacy structure to promote a focus on LGBTQ+ cancer prevention and control.

Increase in Functional Tic Presentations in Sexual Orientation and Gender Identity Minority Youth During Coronavirus Disease 2019.

BACKGROUND: Functional tic disorders are among the least common functional movement disorders, but their prevalence rose during the coronavirus disease 2019 (COVID-19) pandemic. Although female adolescents develop functional neurological disorders at higher rates than males, investigations into sexual orientation and gender identity (SOGI) status of these patients are limited. METHODS: We completed a retrospective, cross-sectional time series examining the incidence of new-onset functional tic disorders in youth presenting to the Massachusetts General Hospital Movement Disorder clinics before and during the COVID-19 pandemic. Data were collected by searching for relevant International Classification of Diseases (ICD)-10 diagnostic codes in youth aged nine to 26 years using a hospital-wide data repository. Individual cases were reviewed for inclusion based on clinical criteria and expert consensus. RESULTS: The prevalence of functional tic presentations in youth rose 8.6-fold from pre- to postpandemic levels (Fisher exact test P < 0.001), whereas the prevalence of developmental tic presentations pre- and postpandemic remained stable (114 vs 112). SOGI minority youth comprised 37% of those with functional tics (total n = 19). Ninety five percent of patients with functional tics identified as female, with 10% of these identifying as transgender. CONCLUSIONS: Our data confirm previously demonstrated dramatic rises in functional tic presentations during the COVID-19 pandemic and, more notably, reveal a strong association with SOGI minority status. We highlight the potential link between functional tic disorders and SOGI minority status. Providing a safe and supportive clinical environment and addressing stress linked to SOGI minority status may help to improve patient prognosis.

LGBTQ+ cardiovascular health equity: a brief review.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. Data shows that social drivers of health (SDOH), including economic stability, racial/cultural identity, and community, have a significant impact on cardiovascular morbidity and mortality. LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other gender and sexual minority) patients face a variety of unique health risk factors and bear a disproportionate burden of CVD compared to cis-gender, heterosexual peers. There is a paucity of research assessing the etiologies of CVD health disparities within the LGBTQ+ community. Herein, we seek to explore existing literature on LGBTQ+ health disparities with a focus on cardiovascular disease, examine trends impacting LGBTQ+ health equity, and identify strategies and interventions that aim to promote LGBTQ+ cardiovascular health equity on a regional and national level.

A Secure Dual-Layer Fault Protection Strategy for Distribution Network with DERs: Enhancing Security in the Face of Communication Challenges.

Earlier protection methods mainly focused on using communication channels to transmit trip signals between the protective devices (PDs), with no solutions provided in the case of communication failure. Therefore, this paper introduces a dual-layer protection system to ensure secure protection against fault events in the Distribution Systems (DSs), particularly in light of communication failures. The initial layer uses the Total Harmonic Distortion (THD), the estimates of the amplitude voltages, and the zero-sequence grid voltage components, functioning as a fault sensor, to formulate an adaptive algorithm based on a Finite State Machine (FSM) for the detection and isolation of faults within the grid. This layer primarily relies on communication protocols for effective coordination. A Second-Order Generalized Integrator (SOGI) expedites the derivation of the estimated variables, ensuring fast detection with minimal computational overhead. The second layer uses the behavior of the positive- and negative-sequence components of the grid voltages during fault events to locate and isolate these faults. In the event that the first layer exposes a communication failure, the second layer will automatically be activated to ensure secure protection as it operates, using the local information of the Protective devices (PDs), without the need for communication channels to transmit trip signals between the PDs. The proposed protection system has been assessed using simulations with MATLAB/Simulink and providing experimental results considering an IEEE 9-bus standard radial system. The obtained results confirm the capability of the system for identifying and isolating different types of faults, varying conditions, and modifications to the grid configuration. The results show good behavior of the initial THD-based layer, with fast time responses ranging from 6 to 8.5 ms in all the examined scenarios. In contrast, the sequence-based layer exhibits a protection time response of approximately 150 ms, making it a viable backup option in the event of a communication failure.

Identifying Strategies for the Use of Gender and Sex Language in Clinical One-Liners.

Purpose: The "one-liner," commonly used in clinical communications, summarizes a patient's identity, presenting condition, medical history, and clinical findings. Imprecise, inconsistent use of gender and sex information in one-liners threatens the provision of affirming care to transgender, nonbinary, gender-expansive, and intersex patients and may exacerbate health care disparities. This study aimed to generate guidance for communicating gender and sex information in one-liners. Methods: This is an explanatory sequential, equal status mixed methods study of transgender, nonbinary, gender-expansive, and intersex people and clinicians caring for this population. Survey participants rated one-liners on a five-point Likert-type scale of appropriateness, considering affirmation and clinical utility, and provided open-ended comments. We conducted two focus groups with survey respondents to explore survey results and performed a thematic analysis of survey comments and focus group transcripts. Results: Survey respondents included 57 clinicians and 80 nonclinicians. One-liners containing patient pronouns were rated most appropriate, and appropriate patient descriptors included self-described gender identity or gender-neutral terms. In scenarios where patient sex information was not pertinent to the chief concern (CC), one-liners containing no sex information were rated most appropriate. Four themes were identified: inclusion of sex information based on relevance to the CC, accurate patient representation, influence of clinical setting, and risk of harm from inaccurate one-liners. Conclusion: This study generated data to support the appropriate use of gender and sex language in one-liners. Clinicians, educators, and trainees may use these findings to compose one-liners that are affirming and clinically useful for patients of diverse gender and sex identities.

Etiology Beliefs About Sexual and Gender Minority Youth (EB-SGM): Validation with College Students, Community Adults, and Pediatric Healthcare Providers.

Sexual and gender minority (SGM) youth are at risk for adverse health outcomes because of stigma and discrimination exposure. Individuals' beliefs about the biological origin of SGM identity are linked to their negative attitudes and biases against SGM populations, which can also apply to pediatric healthcare providers. The current study outlines validation of the Etiology Beliefs about Sexual and Gender Minority Youth (EB-SGM) scale, a 12-item measure designed to assess adults' beliefs about youths' biological versus environmental SGM etiology. College students (N = 285; study 1), community adults (N = 258; study 2), and pediatric providers (N = 104; study 3) completed the EB-SGM and other self-report measures. Exploratory factor analysis (EFA) in study 1 revealed a three-factor structure: beliefs about gender nonconforming behavior, beliefs about gender identity, and beliefs about sexual attraction/behavior. Confirmatory factor analysis (CFA) in study 2 suggested a bi-factor structure, which was replicated in study 3. The EB-SGM demonstrated adequate concurrent and discriminant validity. We also examined bivariate correlations between etiology beliefs and sociodemographic characteristics across samples. Findings indicate that EB-SGM is a psychometrically sound instrument to measure adults' etiology beliefs. The EB-SGM has the potential to be used as a screening measure to enhance pediatric healthcare providers' SGM training.

A Comparative Study of Smart THD-Based Fault Protection Techniques for Distribution Networks.

The integration of Distributed Generators (DGs) into distribution systems (DSs) leads to more reliable and efficient power delivery for customers. However, the possibility of bi-directional power flow creates new technical problems for protection schemes. This poses a threat to conventional strategies because the relay settings have to be adjusted depending on the network topology and operational mode. As a solution, it is important to develop novel fault protection techniques to ensure reliable protection and avoid unnecessary tripping. In this regard, Total Harmonic Distortion (THD) can be used as a key parameter for evaluating the grid's waveform quality during fault events. This paper presents a comparison between two DS protection strategies that employ THD levels, estimated amplitude voltages, and zero-sequence components as instantaneous indicators during the faults that function as a kind of fault sensor to detect, identify, and isolate faults. The first method uses a Multiple Second Order Generalized Integrator (MSOGI) to obtain the estimated variables, whereas the second method uses a single SOGI for the same purpose (SOGI-THD). Both methods rely on communication lines between protective devices (PDs) to facilitate coordinated protection. The effectiveness of these methods is assessed by using simulations in MATLAB/Simulink considering various factors such as different types of faults and DG penetrations, different fault resistances and fault locations in the proposed network. Moreover, the performance of these methods is compared with conventional overcurrent and differential protections. The results show that the SOGI-THD method is highly effective in detecting and isolating faults with a time interval of 6-8.5 ms using only three SOGIs while requiring only 447 processor cycles for execution. In comparison to other protection methods, the SOGI-THD method exhibits a faster response time and a lower computational burden. Furthermore, the SOGI-THD method is robust to harmonic distortion, as it considers pre-existing harmonic content before the fault and avoids interference with the fault detection process.

Geriatric Palliative Care: Providing Excellent Care to Lesbian, Gay, Bisexual, Transgender, Queer Older Adults.

LGBTQ+ patients encounter discrimination and bias in health care settings. They experience worse health outcomes than their cisgender and heterosexual counterparts. There are numerous ways to provide equitable and comprehensive palliative care to seriously ill LGBTQ+ individuals. These strategies include communication techniques, encouragement to complete advance directives, implicit bias training, and interdisciplinary collaboration.

Patient Attitudes on Collection of Sexual Orientation and Gender Identity Data in a Women's Health Clinic with an Embedded Transgender Medicine Program.

Purpose: We examined patient attitudes about the collection of sexual orientation and gender identity (SOGI) data in a mixed sample of sexual and gender minority (SGM) and cisgender heterosexual people. Methods: SOGI questions and an evaluation questionnaire were administered to a convenience sample of patients presenting at an academic women's health clinic with an embedded transgender medicine program. Clinic census is ∼10,000 patients, which includes some 1000 cisgender males and 800 transgender patients. Bivariate and multivariate analyses were performed. Our methods expand on prior study in this area through implementing an analysis which divides the sample into three groups; cisgender heterosexual, cisgender sexual minority, and transgender respondents, and includes an intersectional approach to the analysis by income and age range, race/ethnicity, and presence of a non-English language spoken at home. Results: Some 231 respondents participated out of 291 approached, including 149 cisgender heterosexual respondents, 26 cisgender sexual minority respondents, and 56 transgender people of any sexuality. Scores were high regarding ease and accuracy of the SOGI questionnaire, and willingness to answer SOGI questions. Among those identifying as cisgender/heterosexual, non-White respondents had an odds ratio of 5.48 of being offended by sexual behavior questions compared with White respondents. Respondents overwhelmingly preferred to complete questionnaires through confidential electronic or pen-and-paper means. Conclusion: Patients were overwhelmingly willing to complete SOGI data questionnaires in a clinic setting, and preferred to do so using confidential means rather than by live interview by staff or providers.

Terms which LGBTQI+ individuals prefer or hate to be called by.

Introduction: The evolution of the abbreviation LGBTQI+ comes on the backdrop of numerous studies that were conducted as a form of advocacy to promote the inclusion of LGBTQI+ individuals into society. Objective: This study sought to explore the terms that LGBTQI+ individuals prefer to be called and those they hate to be called by. Methods: The study adopted a qualitative approach underpinned by Husserl's descriptive phenomenological research design. Data was collected through WhatsApp-based semi-structured individual interviews from a 19 participants who were sampled using purposive and snowballing sampling methods. Data analysis was done using Collaizzi's phenomenological analysis method, and all ethical considerations to safeguard participants were adhered to. Results: The analysis yielded two main themes as preferred terminologies and terms that are hated by the LGBTQI+ persons. The findings show an evolution in the terminologies used in relation to the LGBTQI+ identifying persons. Terms such as Queer, LGBTQI+ community, terms confirming gender identity, SOGI neutral, and preferred pronouns emerged as terms that LGBTQI+ people preferred to be called or addressed by. On the other side of the coin, the findings revealed terms that the LBGTQI + people hated as these were perceived to be discriminatory and derogatory, such as terms like "moffie" and "stabane". Conclusion: LGBTQI+ terms are forever evolving and there is a need to raise community awareness and conscientisation towards moving away from the use of derogatory and hateful terms. The hated terms continue to perpetuate verbal abuse, stigmatisation and discrimination of the LGBTQI+ community. Therefore, a nuanced approach to develop and adopt inclusive language policies to promote diversity in public and private spheres.

A secondary mixed methods analysis examining midwives' responses regarding patient sexual orientation and gender identity (SOGI) disclosure.

OBJECTIVE: Recent research suggests that midwives generally have positive attitudes towards sexual and gender minority (SGM) clients; however, little research has examined whether and how these attitudes translate into specific clinical practices. In this study, we performed a secondary mixed methods analysis to examine midwives' beliefs and practices regarding the importance of asking and knowing their patients' sexual orientation and gender identity (SOGI). METHODS: A confidential, anonymous paper survey was mailed to all midwifery practice groups (n = 131) in Ontario, Canada. Participants were midwives who were members of the Association of Ontario Midwives who responded to the survey (n = 267). Sequential explanatory mixed methods analysis was employed: quantitative SOGI questions were analyzed first, followed by qualitative open response comments to explain and contextualize the quantitative findings. FINDINGS: Midwives' responses indicated that it was not important to know or ask about clients' SOGI because (1) it is not necessary to be able to provide the best care to everyone, and (2) the onus is on the client to disclose SOGI. Midwives indicated that they would like more training and knowledge to be able to confidently care for SGM. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Midwives' hesitancy to ask or know SOGI demonstrates that positive attitudes do not necessarily translate into current best practices for obtaining SOGI data in the context of SGM care provision. Midwifery education and training programs should address this gap.

2. Basic Knowledge about Sexual Orientation and Gender Identity, and the Status of Undergraduate Medical Education in Japan and Abroad / 医学教育

LGBTQ people are less visible in Japan and are exposed to minority stress and health disparities due to societal prejudice and discrimination. It is important for healthcare providers to learn about diverse sexual orientations and gender identities to achieve DE&I, in addition to providing equitable healthcare. In Japan, education on LGBTQ topics in medical schools is poor compared to the U.S. and Canada, and there is an urgent need to train faculty to teach this topic, create educational resources, and develop guidelines for medical education.