Improving access to care and delivery to marginalized and vulnerable populations: a committee opinion.

Sexual and gender minorities (SGM) experience detriments across many physical and mental health outcomes compared with heterosexual and cisgender people. But little is known about health outcomes for those who are both gender minorities and sexual minorities. Motivated by theories of double disadvantage and leveraging advancements in data collection and measurement, we examine physical and mental health disparities across sexual and gender minority statuses: cisgender heterosexuals, gender minority heterosexuals, cisgender sexual minorities, and people who are both gender and sexual minorities. Using Gallup's National Health and Well-Being Index (N = 93,144) and the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (N = 543,717), we estimate multivariable logistic regression models to examine how sexual and gender minority statuses are associated with poor/fair self-rated health, functional limitations, and diagnosed depression. Regression models adjusting for sociodemographic characteristics show marked physical and mental health disparities: people who are both gender and sexual minorities report greater odds of poor/fair self-rated health, functional limitations, and depression relative to cisgender heterosexuals and, in some cases, relative to gender minority heterosexuals and cisgender sexual minorities. Our results add to a growing body of research documenting the association between multiple disadvantaged statuses and health and provide novel information on SGM health disparities.

Effective Screening and Treatment to Reduce Suicide Risk Among Sexual and Gender Minority Youth.

Background Sexual and gender minorities face high levels of stigma, discrimination, and violence. In many countries, they are often criminalized and are at risk of mental health challenges. In Zambia, little is known about the psychosocial challenges and coping strategies of sexual and gender minorities. This study sought to explore psychosocial challenges and coping strategies among sexual and gender minority populations in Lusaka, Zambia to inform mental health and human rights promotion for this population. Methods The study used a qualitative phenomenological study design. Data were collected through in-depth interviews with 16 sexual and gender minority participants (lesbian, gay, bisexual, and transgender) and four key informants. The sexual minorities included four lesbian, five gay, and three bisexual participants while the gender minorities included two transgender men and two transgender women. Interviews with gender and sexual minorities were mostly focused on the lived experiences of participants, while those of key informants focused on their work with sexual and gender minorities. Snowball strategy was used to recruit participants, while purposive sampling was used to select key informants. All interviews were recorded and transcribed verbatim. Thematic analysis was carried out with the aid of Nvivo 12 software. Results Psychosocial challenges included victimization in the form of threats and physical assault. Stigma and discrimination were experienced in different settings such as healthcare, the workplace, and school. Participants reported having experienced feelings of depression. Rejection from family members was experienced by those who revealed their sexual or gender minority status. Reported coping strategies included social support, self-concealment, listening to music, and substance use. Conclusion This study suggests that sexual and gender minorities in Zambia experience various psychosocial challenges related to their sexuality and gender identity. To assist them cope better with the obstacles they experience, improved psychosocial counseling and mental health services are needed.

Improving the Experiences of Sexual and Gender Minority-Identifying Trainees in Gastroenterology and Hepatology

This study evaluated short- and long-term impact of a 4-day training intervention to reduce negative perspectives of religious leaders in Kenya on sexual and gender minorities, adopting a one-group pretest-posttest-follow-up design. Religious leaders’ perspectives play an important role in maintaining the negative status quo for sexual and gender minorities, especially in Africa, where religion’s impact is ubiquitous and holding negative attitudes against these populations is perceived as an expression of doctrinal orthodoxy. The training, developed by a community-based organization, employs a variety of strategies, including education, storytelling, and in-person contact. Data were collected directly before and after the training, and at 3- to 4-months follow-up. After the training, acceptance of lesbian women and gay men and gender diversity had increased, while attitudes toward gender and sexual minorities became more positive. Interaction effect analysis showed that compared to women, men changed more, as did those who scored higher on religious fundamentalism. Changes in attitudes were maintained at follow-up (three to four months). Although it is not clear whether the training had an impact on the religious leaders’ interactions with members of their congregation, these findings suggest that intensive trainings may promote positive changes in their perspective on gender and sexual minorities.

Experiencing sexual violence is an important risk factor for trauma symptoms, and these symptoms significantly impair psychosocial functioning. Sexual and gender minority university students are more likely than their heterosexual and cisgender peers to experience sexual violence (e.g., sexual harassment, unwanted sexual contact, or sexual coercion) while attending university, but research on the consequences of these experiences is needed to inform service provision to these vulnerable populations. Using a large-scale study of university-based sexual violence in Quebec, the current study examined how gender and sexual minority status were associated with the severity of trauma symptoms among students who experienced sexual violence (N = 1,196). Findings indicated that compared with their cisgender peers, gender minority students experienced significantly higher levels of trauma symptoms as a result of sexual violence, controlling for the severity of sexual violence behaviors experienced and other variables. Among cisgender women, but not cisgender men, sexual minority identity was also associated with higher levels of trauma symptoms, controlling for severity of sexual violence behaviors experienced and other variables. Furthermore, gender of perpetrator and amount of sexual violence moderated the associations between sexual identity and trauma symptoms among cisgender women. These findings not only suggest that gender minority and some sexual minority university students are more likely to experience sexual violence, but that they are also more likely to experience negative psychological sequelae as a consequence of these experiences. Ultimately, these findings may suggest the need for services that are more supportive of the specific needs of gender and sexual minority students with regard to sexual violence.

While scarce, literature suggests that women at the intersection of HIV status and gender and/or sexual minority identities experience heightened social and health disparities within health care systems. This study examines the association between sexual and/or gender minority identities and: (1) experiences of poor treatment by health professionals and (2) being unable to access health services among a cohort of women living with HIV in Metro Vancouver, Canada. Data were drawn from a longitudinal community-based cohort of women living with HIV (Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment). We examined associations between sexual and/or gender minority identities and the two outcomes. We drew on explanatory variables to measure sexual minority and gender minority identities independently and a combined variable measuring sexual and/or gender minority identities. The associations between each of these three variables and each outcome were analysed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios and 95% confidence intervals are reported. The study sample included 1460 observations on 315 participants over 4.5 years (September 2014 to February 2019). Overall, 125 (39.7%) reported poor treatment by health professionals and 102 (32.4%) reported being unable to access health care services when needed at least once over the study period. A total of 110 (34.9%) of participants reported sexual and/or gender minority identities, 106 (33.7%) reporting sexual minority identities, with 29 (9.2%) reporting gender minority identities. In multivariable analysis, adjusting for confounders, sexual minority identities, and combined sexual and/or gender minority identities were significantly associated with increased odds of experiencing poor treatment by health professionals (sexual minority adjusted odds ratio = 1.39 (0.94-2.05); sexual and/or gender minority adjusted odds ratio = 1.48 (1.00-2.18)) and being unable to access health services (sexual minority adjusted odds ratio = 1.89 (1.20-2.97); sexual and/or gender minority adjusted odds ratio = 1.91 (1.23-2.98)). In multivariable analysis, gender minority identities were not significantly associated with increased odds of experiencing poor treatment by health professionals (gender minority adjusted odds ratio = 1.38; 95% CI = 0.76-2.52) and being unable to access health services (gender minority adjusted odds ratio = 1.72; 95% CI = 0.89-3.31) possibly due to low sample size among women with gender minority identities. Our findings suggest the need for access to inclusive, affirming, trauma-informed health care services tailored specifically for and by women living with HIV with sexual and/or gender minority identities.

Sexual Violence on Campus: Differences Across Gender and Sexual Minority Status

The present study explores how identifying with the gender and sexual minority (GSM) community can be an important developmental milestone and potential protective factor for GSM individuals. Cross-sectional data were collected from the United States using Amazon’s Mechanical Turk (MTurk) to garner a nationally representative sample of individuals (n = 365) between the ages of 18-29 (M = 25.07 years old) who self-identified as a sexual and/or gender minority. Results of a structural equation model indicated that a higher sense of GSM identity salience was associated with greater attribution of their negative experiences to prejudice, which was associated with decreased well-being. Importantly, identifying with the GSM community was a protective factor for this population. Whereas higher attributions of negative experiences to prejudice were directly associated with decreases in well-being, when explained through group identification, the association was positive. This paper extends current research on the GSM community by situating group identification as a process of one’s overall identity development and exploring the protective factors related to this identification. The study highlights the important ways in which connecting with other gender and sexual minority individuals can protect the individuals in this population from the negative outcomes of prejudice.

Sexual and gender minority (SGM) groups have been historically underrepresented in neurologic research, and their brain health disparities are unknown. We aim to evaluate whether SGM persons are at higher risk of adverse brain health outcomes compared with cisgender straight (non-SGM) individuals. We conducted a cross-sectional study in the All of Us Research Program, a US population-based study, including all participants with information on gender identity and sexual orientation. We used baseline questionnaires to identify sexual minority (lesbian, gay, bisexual, diverse sexual orientation; nonstraight sexual orientation) and gender minority (gender diverse and transgender; gender identity different from sex assigned at birth) participants. The primary outcome was a composite of stroke, dementia, and late-life depression, assessed using electronic health record data and self-report. Secondarily, we evaluated each disease separately. Furthermore, we evaluated all subgroups of gender and sexual minorities stratified by sex assigned at birth. We used multivariable logistic regression (adjusted for age, sex assigned at birth, race/ethnicity, cardiovascular risk factors, other relevant comorbidities, and neighborhood deprivation index) to assess the relationship between SGM groups and the outcomes. Of 413,457 US adults enrolled between May 31, 2017, and June 30, 2022, we included 393,041 participants with available information on sexual orientation and gender identity (mean age 51 [SD 17] years), of whom 39,632 (10%) belonged to SGM groups. Of them, 38,528 (97%) belonged to a sexual minority and 4,431 (11%) to a gender minority. Compared with non-SGM, SGM persons had 15% higher odds of the brain health composite outcome (odds ratio [OR] 1.15, 95% CI 1.08-1.22). In secondary analyses, these results persisted across sexual and gender minorities separately (all 95% CIs > 1). Assessing individual diseases, all SGM groups had higher odds of dementia (SGM vs non-SGM: OR 1.14, 95% CI 1.00-1.29) and late-life depression (SGM vs non-SGM: OR 1.27, 95% CI 1.17-1.38) and transgender women had higher odds of stroke (OR 1.68, 95% CI 1.04-2.70). In a large US population study, SGM persons had higher odds of adverse brain health outcomes. Further research should explore structural causes of inequity to advance inclusive and diverse neurologic care.

Objectives. To determine the levels and differentials in health care stereotype threat experienced during the COVID-19 pandemic by individuals with sexual or gender minority identities. Methods. The National Couples' Health and Time Use Study is a national cross-sectional US population‒ based sample of partnered individuals interviewed during the pandemic between September 2020 and April 2021 with oversamples of sexual and gender minority individuals. The analytic sample consisted of 3614 individuals (n = 2043 heterosexual and n = 1571 sexual minority individuals along with 3489 cisgender and 125 noncisgender people). Results. Individuals with sexual minority identities experienced significantly more health care stereotype threat than heterosexual people. Cisgender women and those with another gender identity experienced significantly more health care stereotype threat than cisgender men. These results persisted after the inclusion of indicators of health conditions, insurance, COVID-19 experience, and sociodemographic factors. Conclusions. Gender and sexual minority‒identifying people reported high levels of worries about health discrimination. Our work suggests that providing positive health care experiences may reduce these worries and offer a potential antidote to sexual and gender minority health disparities that are driven by structural and interpersonal discrimination. These findings support calls for the further education and transformation of health care provision and systems. (Am J Public Health. 2025;115(3):425-433. https://doi.org/10.2105/AJPH.2024.307926).

Human–animal interaction (HAI) research is growing in popularity and methodological rigor; however, there remains a need for psychometrically validated measures and inclusion of broader populations. This study addressed these gaps by reporting on the psychometric properties of the Comfort from Companion Animals Scale (CCAS) in a sample of sexual and gender minority emerging adults. Participants included 138 emerging adults between the ages of 18–21 years (M = 19.33 years, SD = 1.11; 38.4% racial/ethnic minority) who identified as a gender (48.6%) and/or sexual minority (98.6%) and who reported living with a companion animal in the past year. We utilized the following analytic methods: (a) confirmatory factor analyses to compare the unidimensional structure of the CCAS with the two alternative models, (b) multiple group analyses to test measurement invariance across demographic groups, and (c) structural equation models to evaluate construct validity. Preliminary analysis found that the majority of participants did not endorse the two lowest response options. To conduct invariance testing, we eliminated items 3, 5, and 8 from the CCAS and collapsed the lowest response options. The results of the confirmatory factor analysis supported the use of this revised unidimensional model. We found evidence of measurement invariance across gender identity, sexual orientation, and race/ethnicity groups. Construct validity was supported by comparing the CCAS with factors on the Pet Attachment and Life Impact Scale; the positive association between the CCAS and anxiety are discussed in the context of prior research. Overall, our findings highlight the importance of validating HAI measures across samples from diverse backgrounds. We recommend that future studies continue to test the CCAS and other measures of human–animal attachment among diverse samples to delineate which aspects of HAI may be most beneficial in promoting mental health in vulnerable populations.

BackgroundPeople identifying as sexual and gender minorities (SGM) may have higher risk for subjective cognitive decline and Alzheimer’s disease, although the risk for Parkinson’s disease dementia (PDD) has not been investigated. Male sex is associated with a higher risk for PDD, it is unclear whether SGM status impacts the risk.MethodsData were obtained from Fox Insight on April 5th, 2023. The analysis included people (1) with adult‐onset Parkinson’s, (2) responding to questions on sex assigned at birth, gender identity, sexual orientation, (3) with at least one available Penn Parkinson’s Daily Activities Questionnaire‐15 (PDAQ‐15), (4) without dementia at baseline, based on the first PDAQ‐15 (>43). Groups consisted of people identifying as (1) SGM with female sex assigned at birth (SGM‐F, n = 75); (2) cisgender, heterosexual women (CHW, n = 2,046); (3) SGM with male sex assigned at birth (SGM‐M, n = 84); (4) cisgender, heterosexual men (CHM, n = 2,056). Sex assigned at birth and SGM status effects on dementia likelihood during follow‐up were assessed with generalized linear mixed models.ResultsOut of 159 people identifying as SGM, eight (5.0%) identified as gender minorities, 144 (90.6%) identified as sexual minorities, seven (4.4%) identified as both gender and sexual minorities. At baseline, people with female sex had better PDAQ‐15 scores than people with male sex assigned at birth; SGM‐M had the lowest scores. SGM‐M had a higher dementia likelihood compared to people not identifying as SGM. After adjusting for age, education, employment status, income, perceived discrimination level, age at Parkinson’s diagnosis, baseline PDAQ‐15 scores, that differed across groups at baseline, dementia likelihood was lower for CHW compared to people with male sex assigned at birth.ConclusionsFor PDD, SGM‐M can be at a higher risk than CHM; people with female sex can have a lower risk than people with male sex assigned at birth. Socioeconomic disadvantages can alter the sex effect on PDD risk, by putting SGM‐M at a higher risk and females at a similar risk level compared to people with male sex assigned at birth, as shown in unadjusted models. Socioeconomic disadvantages should be acknowledged and addressed to support the well‐being of SGM with Parkinson’s.

There is substantial corroborating evidence that orthopaedic surgery has historically been the least diverse of all medical and surgical specialties in terms of race, ethnicity, and sex. Growing recognition of this deficit and the benefits of a diverse healthcare workforce has motivated policy changes to improve diversity. To measure progress with these efforts, it is important to understand the existing representation of sexual and gender minorities among orthopaedic professionals. (1) What proportion of American Academy of Orthopaedic Surgeons (AAOS) members reported their identity as a sexual or gender minority? (2) What demographic factors are associated with the self-reporting of one's sexual orientation and gender identity? The AAOS published the updated membership questionnaire in January 2022 to collect information from new and existing society members regarding age and race or ethnicity and newly added categories of gender identity, sexual orientation, and pronouns. The questionnaire was updated with input from a committee of orthopaedic surgeons and researchers to ensure face validity. The AAOS provided a deidentified dataset that included the variables of interest: membership type, gender identity, sexual orientation, pronouns, age, race, and ethnicity. Of 35,427 active AAOS members, 47% (16,652) updated their membership questionnaire. To answer our first study question, we calculated the prevalence of participants who self-reported as lesbian, gay, bisexual, transgender, queer, or another sexual or gender minority identity (LGBTQ+) and other demographic characteristics of the 16,652 respondents. Categorical demographic data are described using frequencies and proportions. Median and IQR were used to describe the central tendency and variability. To answer our second study question, we conducted a stratified analysis to compare demographic characteristics between those who self-reported LGBTQ+ identity and those who did not. Visual methods (quantile-quantile plots) and statistical tests (Kolmogorov-Smirnov and Shapiro Wilk) confirmed that the age of AAOS member was not normally distributed. Therefore, a Kruskal Wallis test was used to determine the statistical associations between age and self-reported LGBTQ+ status. Chi-square tests were used to determine bivariate statistical associations between categorical demographic characteristics and self-reported LGBTQ+ status. A multivariable logistic regression model was developed to identify the independent demographic characteristics associated with respondents who self-reported LGBTQ+ identity. Further stratified analyses were not conducted to protect the anonymity of AAOS members. An alpha level of 5% was established a priori to define statistical significance. Overall, 3% (109 of 3679) and fewer than 1% (3 of 16,182) of the AAOS members (surgeons, clinicians, allied healthcare providers, and researchers) who updated their membership profiles reported identifying as a sexual (lesbian, gay, bisexual, queer) or gender minority (nonbinary or transgender), respectively. No individual self-identified as transgender. Five percent (33 of 603) of women and 3% (80 of 3042) of men self-identified as a sexual minority (such as lesbian, gay, bisexual, or queer). AAOS members who self-identified as LGBTQ+ were younger (OR 0.99 [95% confidence interval (CI) 0.98 to 0.99]; p < 0.001), less likely to self-identify as women (OR 0.86 [95% CI 0.767 to 0.954]; p < 0.001), less likely to be underrepresented in medicine (OR 0.49 [95% CI 0.405 to 0.599]; p < 0.001), and less likely to be an emeritus or honorary member (OR 0.75 [95% CI 0.641 to 0.883]; p < 0.003). The proportion of self-reported LGBTQ+ AAOS members is lower than the 7% of the general US population. The greater proportion of younger AAOS members reporting this information suggests progress in the pursuit of a more-diverse field. The study findings support standardized collection of sexual orientation and gender identity data to better identify and address diversity gaps. As orthopaedic surgery continues to transform to reflect the diversity of musculoskeletal patients, all orthopaedic professionals (surgeons, clinicians, allied healthcare providers, and researchers), regardless of their identities, are essential in the mission to provide equitable and informed orthopaedic care. Sexual and gender minority individuals may serve as important mentors to the next generations of orthopaedic professionals; individuals from nonminority groups should serve as important allies in achieving this goal.

Substantial empirical evidence suggests that individuals who belong to sexual and gender minorities experience more anxiety and depression than heterosexual and cisgender people. Many previous studies have not, however, used population-based samples. There is also a shortage of evidence about certain sexual and gender minorities (e.g., nonbinary individuals). We examined differences in levels of anxiety and depression within sexual and gender minorities, as well as compared to the heterosexual and cisgender majority in a population-based Finnish sample (N = 8,589). We also explored if individuals who belong to both a gender and a sexual minority (double minority) reported higher rates of anxiety and depression than individuals who hold either a gender or a sexual minority status (single minority). Individuals who belonged to either a sexual or a gender minority overall experienced significantly higher rates of anxiety and depression than cisgender and heterosexual individuals. Among the different sexual and gender minorities, bisexual, emerging identity, and nonbinary individuals reported the highest rates of anxiety and depression. We found no differences in anxiety and depression between single minority and double minority individuals. Our results suggest that even though Finland is a country with an inclusive social climate, sexual and gender minorities are, nevertheless, disproportionately affected by mental health issues. The present study gives further support to the claim that individuals holding a sexual or gender minority status experience higher levels of depression and anxiety compared to cisgender and heterosexual individuals and pinpoints the need to acknowledge these issues both in the context of health care and in the society at large.