Structural Stigma Research Articles

Addressing stigma within the dissemination of research products to improve quality of care for pregnant and parenting people affected by substance use disorder.

Substance use disorders are a common and treatable condition among pregnant and parenting people. Social, self, and structural stigma experienced by this group represent a barrier to harm reduction, treatment utilization, and quality of care. We examine features of research dissemination that may generate or uphold stigmatization at every level for pregnant and parenting individuals affected by substance use disorder and their children. We explore stigma reduction practices within the research community that can increase uptake of evidence-based treatment programs and prevent potential harm related to substance use in pregnant and parenting people. The strategies we propose include: (1) address researcher stereotypes, prejudice, and misconceptions about pregnant and parenting people with substance use disorder; (2) engage in interdisciplinary and transdisciplinary collaborations that engage with researchers who have lived experience in substance use; (3) use community-based approaches and engage community partners, (4) address stigmatizing language in science communication; (5) provide contextualizing information about the social and environmental factors that influence substance use among pregnant and parenting people; and (6) advocate for stigma-reducing policies in research articles and other scholarly products.

Accessing hepatitis C direct acting antivirals among people living with hepatitis C: a qualitative study

BackgroundHepatitis C is curable with direct-acting antivirals (DAAs). However, treatment uptake remains low among marginalized populations such as people who inject drugs. We sought to understand challenges to treatment uptake with DAAs among people living with hepatitis C and compare treatment experiences between people who do and do not inject prescription and/or unregulated drugs.MethodsWe conducted a qualitative study using focus groups with 23 adults aged 18 years and over who completed DAA treatment or were about to begin such treatment at the time of the study. Participants were recruited from hepatitis C treatment clinics across Toronto, Ontario. We drew upon stigma theory to interpret participants’ accounts.ResultsFollowing analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing DAAs: “being ‘worthy’ of the cure”, “spatially enacted stigma”, “countering social and structural vulnerability: the importance of peers”, “identity disruption and contagion: attaining a ‘social cure’” and “challenging stigma with population-based screening”. Overall, our findings suggest that structural stigma generated and reproduced through healthcare encounters limits access to DAAs among people who inject drugs. Peer-based programs and population-based screening were proposed by participants as mechanisms for countering stigma within health care settings and ‘normalizing’ hepatitis C among the general population.ConclusionsDespite the availability of curative therapies, access to such treatment for people who inject drugs is limited by stigma enacted in and structured within healthcare encounters. Developing novel, low-threshold delivery programs that remove power differentials and attend to the social and structural determinants of health and reinfection are needed to facilitate further scale up of DAAs and support the goal of eradicating hepatitis C as a public health threat.

Disparities in Subjective Well-being by Sexual Orientation: Comparing Cohorts from pairfam’s (2008-09) and FReDA’s (2021) Baseline Waves

Significant expansion of legal rights and recognition of sexual minority populations triggered expectations that structural stigma, sexual minority stress and, consequently, previously well-documented disadvantages in health and well-being may decline over time. The empirical evidence on this issue is, however, still sparse and inconclusive. We contribute to this research by comparing baseline data from the German Family Panel (pairfam; 2008-09) and the German Family Demography Panel Study (FReDA; 2021). These data allow us to assess disparities in subjective well-being by sexual orientation and potential changes therein after legalisation of same-sex marriage in Germany in two adult cohorts interviewed more than a decade apart. We focus on two specific outcomes, namely life satisfaction and self-rated health. Two main findings emerged from our analysis: First, minority sexual orientation is associated with significantly lower subjective well-being, specifically lower life satisfaction. Second, there are no statistically significant changes in the sexual orientation-health nexus between cohorts. Our study, thus, neither lends support to “optimistic” expectations regarding the contribution of (further) reductions in institutional discrimination and structural stigma to (further) reductions in remaining disadvantages, nor does it lend support to “pessimistic” expectations suggesting that younger cohorts of sexual minority adults may experience an even larger gap in health and well-being than previous cohorts. We propose that the stability of sexual minorities’ disadvantages in subjective well-being during the first two decades of the 21st century in Germany be interpreted as the result of two opposing forces working in parallel: Reduced institutional discrimination and increased exposure to continued stigma. The legal recognition of same-sex relationships appears to be a necessary but not sufficient condition for the acceptance of sexual minorities. Remaining disparities by sexual orientation will thus not simply disappear when institutional discrimination of sexual minorities is eliminated. Currently, we may therefore find ourselves in a “transitory period” whose further evolution is difficult to predict. FReDA – with its evolving longitudinal dimension and the inclusion of self-reported measures of respondents’ sexual orientation – will constitute a powerful resource for future investigations of inequalities in yet understudied but increasingly visible sexual minority populations. * This article belongs to a special issue on “Family Research and Demographic Analysis – New Insights from the German Family Demography Panel Study (FReDA)”.

The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes

BackgroundAccording to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries.MethodsBy using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics.ResultsCountry-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear.ConclusionThe results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.

Canon, Catechism, and Curriculum: GSAs and Student Mental Health in Ontario Catholic Schools

The permissibility of student GSA (Gender Sexuality Alliance) clubs in Ontario has been heavily disputed, with Catholic schools showing particular resistance. With a history of opposing same-sex rights, Canada’s Catholic Church holds great social, economic, and political power. This institution-level power generates extensive structural stigma that harms the LGBTQ community, including adolescents. Stigmatization provokes emotional, cognitive, behavioural, and physiological responses that compound each other, altering one’s health. Through the use of accepted socio-epidemiological guidelines for establishing causal inference along with data from a Canadian report on homophobia and transphobia in both Catholic and public schools, it is evident that structural stigma, expressed through prejudice against GSAs in Ontario Catholic schools, is harmful to the health of LGBTQ students. LGBTQ students, who are structurally stigmatized in Ontario Catholic schools, experience inferior emotional health compared to their nonstigmatized cisgender and heterosexual peers. Literature reviewed demonstrates confidence in a causal relationship; due to the structural stigma that Catholic schools in Ontario perpetuate against the LGBTQ community, LGBTQ students attending these schools experience greater risks to their mental health. It is imperative that LGBTQ youth are protected in schools, and solutions must be considered to balance Catholic religious rights in education with the health and social needs of students.

“Coming out of the closet about sexual assault”: Intersectional sexual assault stigma and (non) disclosure to formal support providers among survivors using Reddit

Sexual assault is a pervasive, violent and often gendered crime that can result in significant negative consequences. Many sexual assault survivors consider disclosing to health and social care providers, therapists, and others who collectively fall under the banner of formal support, in order to access information, referrals, treatment and/or emotional support, however barriers to disclosure remain. This qualitative study is unique in its application of an intersectional sexual assault stigmatization framework to understand (non)disclosure to formal support providers among diverse sexual assault survivors. Through anonymous online narratives posted to the platform Reddit, survivors documented experiences of intersectional sexual assault stigma (perceived, internalized, anticipated, experienced) showing that they were not only stigmatized through negative gender stereotyping, but they were also marginalized through other structural inequities. The experience of multiple marginalization that arose from intersectional sexual assault stigma often impeded survivors in accessing and/or utilizing the formal support they wished for. The findings suggest that formal support providers could benefit from stigma reduction training related specifically to sexual assault survivors and that current models of stigma and discrimination training need to be expanded to include intersectional stigma. Further, the findings suggest that beyond training at an organizational level, a broader intervention aimed at reducing structural stigma and discrimination toward sexual assault survivors at a societal level appears warranted. Implications for future research related to the unique disclosure, health, and social care needs of diverse sexual assault survivors and support-seeking online alongside or in lieu of formal support are discussed.

“Monogamy? In this Economy?”: Stigma and Resilience in Consensual Non-Monogamous Relationships

Monogamous marriage, sometimes called “the bedrock of society,” still carries an apparent “halo” of moral superiority as a relationship structure. In contrast, consensual non-monogamous (CNM) configurations are stigmatized. Research indicates a connection between stigma, stress, and negative health outcomes, despite CNM comparing favorably with monogamy. The present study uses interviews to explore minority stress and resilience among individuals in CNM relationships. Participants experienced structural stigma as erasure, and interpersonal stigma as erasure and educational/emotional work. They also describe complex enmeshment between their relationship minority status and other aspects of their sexual and gender identities. Strategic disclosure and concealment were important management tools. Furthermore, managing individual (internalized) stigma was described as unlearning mononormative bias and surrounding oneself with supportive peers/allies. The strongest motivator for perseverance was the steadfast conviction that the advantages of CNM outweighed the challenges.

Measuring structural HIV stigma

Despite the progress in pharmaceutical and epidemiological tools for combating HIV spread, HIV stigma remains a significant social barrier impeding treatment and prevention efforts, potentially reducing the effectiveness of interventions to reduce HIV transmission. In this paper, we propose a novel approach to defining and estimating HIV stigmatization through the structure of sexual relations, as opposed to attitudes. We conceptualize structural stigma as arising from two mechanisms: (1) a reduced propensity towards HIV serodiscordant partnerships (exclusion); and (2) a reduced propensity towards partnerships with seroconcordant individuals who themselves have serodiscordant partnerships (ostracism). Both mechanisms can be assessed from observed partnership network data using exponential family random graph models (ERGMs). We demonstrate our approach on a sexual contact network of black men who have sex with men in the South Side of Chicago. We find a tendency for serodiscordant sexual relationships to be suppressed in the network (θ = −0.69, p < .05), as well as a suppressive tendency for HIV negative YBMSM to have sex with other HIV negative people in serodiscordant relationships (θ = −0.96, p < .05) suggesting that structural HIV stigma is present in this network. Potential relationships with attitudinal stigma and implications for epidemiological strategies for reducing HIV stigma are discussed.

Comment l’évolution de l’opinion publique et des réformes législatives influence-t-elle la satisfaction de vie des minorités sexuelles ?

Structural stigma in the form of legal discrimination and population acceptance of same-sex relationships vary greatly across European countries. Previous cross-sectional research has linked such county variation in stigma with life-satisfaction among sexual minorities, but the consequences of the past decade's improvement in legal recognition and social acceptance of same-sex relationships are unknown. In the current study, we, therefore, examined the change in life-satisfaction among sexual minorities between 2012 and 2019 in France, Sweden, and Poland - three countries for which the legal situation and social acceptance of sexual minorities have changed in different directions during the past decade. Between April and July 2012, and again between May and July 2019, the European Union Agency for Fundamental Rights conducted web-based surveys to monitor the fundamental rights situation affecting lesbian, gay, and bisexual (LGB) individuals, living in 28 European countries. For the current study, we analyzed data from all LGB respondents in France, Sweden, and Poland, with no history of migration in 2012 (n = 12,357) and 2019 (n = 21,858). Regression models adjusted for age, gender, education, and relationship status, showed a strong and significant improvement in life-satisfaction among sexual minorities in France between 2012 and 2019 (β = 0.397, 95 % CI: 0.337, 0.457, p &lt; .001), a country that had experienced improvements in legal recognition (e.g., same-sex marriage legislation in 2013) and improved social acceptance during the same period. In Sweden, which had a high degree of legal recognition and social acceptance in place already in 2012, we found a small increase life-satisfaction among sexual minorities between 2012 and 2019 (β = 0.188, 95 % CI: 0.042, 0.333, p = .012). In Poland, who had experienced deteriorating social acceptance between 2012 and 2019, we found a declined in life-satisfaction among sexual minorities (β = - 0.289, 95 % CI: - 0.385, - 0.193, p &lt; .001). Although life satisfaction has increased during the past decade among sexual minorities living in Europe, there are significant variations across countries largely due to the structural stigma and degree of legal recognition of same-sex relationships of those countries. The findings highlight the importance of further efforts to reduce structural stigma by improving legal recognition and social acceptance of same-sex relationships to promote equitable life satisfaction.

Reported HIV-related stigma according to race and ethnicity

ABSTRACT People living with HIV/AIDS (PLWHA) have long experienced structural, community, and personal stigma. We explored differences in experienced HIV-related stigma according to race/ethnicity using quantitative and qualitative measures. Sixty-four patients were enrolled in this study (22 White and 42 people of color [POC]). POC scored higher than White PLWHA on all 12 survey statements, with statistically significant differences in disclosure concerns and with one of the statements on public attitudes towards PLWHA. Common themes in the qualitative interview were HIV disclosure concerns and fear of rejection. These data demonstrate that stigma continues to be a significant concern for PLWHA, particularly POC, meaningfully impacting their lives. By acknowledging and working to reduce negative perceptions about PLWHA, physicians may improve care for their patients by developing more trusting relationships.

Association between burnout and stigma in physicians.

Physicians suffering from burnout are more likely to develop depression, substance dependence, and cardiovascular diseases, which can affect their practices. Stigmatization is a barrier to seeking treatment. This study aimed to understand the complex links between burnout among medical doctors and the perceived stigma. Online questionnaires were sent to medical doctors working in five different departments of the Geneva University Hospital. The Maslach Burnout Inventory (MBI) was used to assess burnout. The Stigma of Occupational Stress Scale in Doctors (SOSS-D) was used to measure the three stigma dimensions. Three hundred and eight physicians participated in the survey (response rate: 34%). Physicians with burnout (47%) were more likely to hold stigmatized views. Emotional exhaustion was moderately correlated with perceived structural stigma (r = 0.37, P < .001) and weakly correlated with perceived stigma (r = 0.25, P = 0.011). Depersonalization was weakly correlated with personal stigma (r = 0.23, P = 0.04) and perceived other stigma (r = 0.25, P = 0.018). These results suggest the need to adjust for existing burnout and stigma management. Further research needs to be conducted on how high burnout and stigmatization impact collective burnout, stigmatization, and treatment delay.

“Testing the Waters” in a “World That Refuses to Make Space: Development and Coming Out with Transgender and Non-Binary Adults

ABSTRACT Transgender and gender non-binary (TGNB) adults face structural and interpersonal stigma from their families and society at large when living openly and seeking gender affirming healthcare. To better understand the significance of family and social contexts for shaping the lived experiences of TGNB adults, this phenomenological qualitative study aimed to describe TGNB transgender identity development and coming out processes inclusive of significant past and present experiences. TGNB participants (N = 17) completed a one-time semi-structured interview and member checking of analysis findings. Results identified two themes: 1) TGNB identity development and socially “testing the waters” in gender expression; and 2) coming out when “the world just refuses to make space.” Implications are made for advancing feminist systemic research and clinical practice with TGNB clients.

"You'll come in and dose even in a global pandemic": A qualitative study of adaptive opioid agonist treatment provision during the COVID-19 pandemic.

Opioid agonist treatment (OAT) improves multiple health and social outcomes, yet requirements to attend for supervised dosing can be burdensome and stigmatising. The COVID-19 pandemic and associated restrictions threatened continuity of care and the wellbeing of people receiving OAT, risking a parallel health crisis. This study sought to understand how adaptations in the complex system of OAT provision impacted and responded to risk environments of people receiving OAT during the COVID-19 pandemic. The analysis draws on semi-structured interviews with 40 people receiving and 29 people providing OAT located across Australia. The study considered the risk environments that produce COVID-19 transmission, treatment (non-)adherence, and adverse events for people receiving OAT. Drawing on theories of risk environments and complex adaptive systems, data were coded and analysed to understand how adaptations to the typically rigid system of OAT provision impacted and responded to risk environments during the COVID-19 pandemic. During COVID-19, the complex system of OAT provision demonstrated possibilities for responsive adaptation to the entangled features of risk environments of people receiving OAT. Structural stigma was evident in the services which stayed rigid during the pandemic, requiring people to attend for daily supervised dosing and risking fracturing therapeutic relationships. In parallel, there were several examples of services developing enabling environments by offering flexible care through increased takeaways, treatment subsidies, and home delivery. Rigidity in the delivery of OAT has been an impediment to achieving health and wellbeing over past decades. To sustain health-promoting environments for people receiving OAT, the wider impacts of the complex system should be acknowledged beyond narrowly defined outcomes relating solely to the medication. Centring people receiving OAT in their own care plans will ensure adaptations in the complex system of OAT provision are responsive to the individual's risk environment.

State Protection Alignment Index as a Measure of Structural Stigma’s Impact on the Mental Health of Sexual and Gender Minorities

Sexual and gender minority (SGM) populations are vulnerable to health disparities, including worse mental health when compared with cisgender, heterosexual populations. This is in part due to the stigma and discrimination they experience. In this study, we used a novel approach to examine structural-level stigma by determining which categories of statewide law and policy protections for SGM people were associated with mental health outcomes among SGM adults. This was a cross-sectional study using law and policy data compiled by the Human Rights Campaign health data and collected through the Behavioral Risk Factor Surveillance System survey in the United States between January and December of 2019. We applied the weighted quantile sum regression to generate the Protection Alignment Index (PAI) from the 10 SGM categories of laws and policies and evaluated the influence of the PAI on the number of days of poor mental health and a diagnosis of depression. SGM people living in states with a higher SGM PAI, indicating greater protections, had significantly fewer poor mental health days. When the PAI increased one interquartile range (IQR≈0.75), the log of expected poor mental health days significantly decreased −0.04 days (95% CI = −0.08, −0.01;p-value = 0.012). Additionally, the odds of depression was 22% lower (OR = 0.78; 95% CI = 0.62, 0.98;p-value = .033) when the SGM PAI increased one IQR (≈0.77). Findings from this study indicate that whether laws and policies discriminate against or protect SGM people impacts the levels of structural stigma and ultimately mental health. Advocating for more protective laws and policies may be a way to help improve the mental health of SGM populations.

The reasons and significance of same-sex marriage on the LGBT community in Latin America

ver the past decade, Latin America has stood out for recognizing LGBT rights and made impressive progress on marriage equality. Since 2010, nine countries have approved laws prohibiting discrimination based upon sexual orientation. Argentina became the first country in the region to approve same-sex marriage in 2010. The rest are Uruguay in 2013, Brazil in 2013, Colombia in 2016, Ecuador in 2019, Costa Rica in 2020, Chile in 2021, Mexico in 2022, and Cuba in 2022. Why can same-sex marriage be legalized in Latin America? The essence of the legalization of same-sex marriage is an expansion of the LGBT groups’ rights, primarily due to institutional factors in Latin America: party affiliation, federalism, and the role of the courts. The significance of legalizing same-sex marriage for LGBT groups is improving their mental health, preventing discrimination and violence against the LGBT community, strengthening gender equality, and avoiding lavender marriage. At the social level, legalization could enhance the development of society by removing the structural stigma of LGBT people and strengthening health systems. Argentina has the features to achieve success in this field.

Implementation and effectiveness of transgender stigma reduction interventions in sub-Saharan Africa: a scoping review.

The transgender or trans population is one of the most marginalized social groups globally, frequently experiencing ill-treatment and discrimination. This is disproportionately higher in sub-Saharan Africa where trans people experience stigma even in healthcare settings. There is limited evidence concerning the implementation and outcomes of interventions to mitigate this stigma. Therefore, this scoping review aimed to describe interventions and determine their effectiveness in reducing transgender stigma in sub-Saharan Africa. Searches (completed November 01, 2021, and re-run May 2022) were conducted in MEDLINE (via PubMed), Cochrane Library including the Cochrane Central Register of Controlled Trials, EBSCOhost, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of science, clinicaltrials.gov, and online grey literature sources to identify publications that described interventions to reduce transgender stigma in sub-Saharan Africa. From 877 literature search results, 23 full-text articles were assessed. Data were extracted from the four (4) eligible papers. Only one study explicitly mentioned transgender people. Second, while two studies incorporated conceptual frameworks, they did not show how the frameworks guided the study. The four studies implemented unique interventions at various socio-ecological levels to address individual and interpersonal and structural stigma. Each study utilized a different methodological approach, and the interventions were all evaluated qualitatively. There is a paucity of transgender stigma reduction interventions implemented in Sub-Saharan Africa with limited evidence of interventions delivered to mitigate stigma at interpersonal and structural levels. Future anti-transgender stigma research should consider reporting details about the core components and descriptions of the interventions. Additionally, the use of validated measures of stigma and the evaluation of interventions for implementation outcomes would be helpful.

Development of an acceptance based PrEP intervention (ACTPrEP) to engage young black MSM in the South utilizing the Adaptome Model of intervention adaptation

ObjectivesHIV disproportionately affects young Black men who have sex with men (YBMSM) in the Southern United States. Pre-exposure prophylaxis (PrEP) is an efficacious, biomedical approach to prevent HIV. While Mississippi (MS) has among the highest rates of new HIV infections, it also ranks among the top three states for unmet PrEP need. Thus, increasing engagement in PrEP care for YBMSM in MS is imperative. A potential method to improve psychological flexibility and promote PrEP uptake, explored by this study, is the incorporation of Acceptance and Commitment Therapy (ACT) into PrEP interventions. ACT is an evidence-based intervention used to treat a wide range of mental and physical illnesses. MethodsTwenty PrEP-eligible YBMSM and ten clinic staff working with YBMSM in MS were surveyed and interviewed between October 2021 and April 2022. The brief survey covered PrEP structural barriers, PrEP stigma, and psychological flexibility. Interview topics included internal experiences related to PrEP, existing health behaviors, PrEP related personal values, and relevant constructs from the Adaptome Model of Intervention Adaptation (service setting, target audience, mode of delivery, and cultural adaptations). Qualitative data were coded based on ACT and the Adaptome model, organized using NVivo, then thematically analyzed. ResultsPatients identified side effects, costs, and taking a daily prescription as top barriers to taking PrEP. Staff reported the top barrier to PrEP for clients was concern others would believe they were living with HIV. Levels of psychological flexibility and inflexibility varied widely among participants. The resulting thematic categories derived from the interviews included 1) thoughts, emotions, associations, memories, and sensations (TEAMS) related to PrEP and HIV, 2) general health behaviors (existing coping techniques, views on medication, HIV/PrEP approach and avoidance), 3) values related to PrEP use (relationship values, health values, intimacy values, longevity values), and 4) Adaptome Model adaptations. These results informed the development of a new intervention, ACTPrEP. ConclusionsInterview data organized by the Adaptome Model of Intervention Adaptation determined appropriate ACT-informed intervention components, content, intervention adaptations, and implementation strategies. Interventions informed by ACT that help YBMSM endure short-term discomfort related to PrEP by relating it to their values and long-term health goals are promising for increasing individuals’ willingness to initiate and maintain PrEP care.

Smoking Cessation Interventions for LGBT Populations: A Scoping Review and Recommendations for Public Health

Members of the lesbian, gay, bisexual, transgender (LGBT) community are at increased risk for health threats when compared to their peers, including significantly higher rates of cigarette smoking and tobacco use, conferring risks for preventable tobacco-related illnesses and cancers. Health disparities for this group are associated with social and structural inequities, stigma and discrimination. As such, there are systemic and societal barriers to accessing smoking cessation services and too few services aim to reach and engage these groups. To date, three reviews have systematically summarized the literature about smoking cessation programs in LGBT samples; one review focused on young adults only, one review is eight years old, and one was focused on Australian policy. We conducted a scoping review of the literature and identified 71 studies examining smoking cessation in LGBT groups. Implementation barriers included in these studies were coded by raters. No studies were found that summarized or describe implementation science models for smoking cessation programs for LGBT groups. The Dynamic Sustainability Framework provides a structure for disseminating and implementating recommendations from smoking cessation research for practical use with LGBT communities. Interventions exist at the individual, family, systems, and national policy levels. More research is needed to determine whether tailoring or targeting of interventions matters. Using the Framework for Knowledge Translation, we created an easily disseminable sheet of information for community partners about how to use the lessons learned from these research articles to increase access to smoking cessation for LGBT individuals and communities and to increase public health.

Lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) healthcare in Singapore: perspectives of non-governmental organisations and clinical year medical students

ABSTRACT Purpose International studies document that lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) patients face significant health disparities. Studies exploring the attitudes, knowledge, preparedness and comfort levels of healthcare students towards LGBTQI+ health have been conducted in the United States, United Kingdom and Malaysia. This study aims to investigate stigma in healthcare for LGBTQI+ patients in Singapore, and possible upstream factors within medical education. Methods This mixed-methods study adopts a convergent parallel design. The Health Stigma and Discrimination Framework was referenced to devise in-depth interviews with representatives from 13 LGBTQI-affirming non-governmental organisations, analysed through thematic analysis. 320 clinical medical students were surveyed about attitudes, knowledge, comfort, preparedness, and perceived importance of/towards LGBTQI+ health, analysed via descriptive statistics and multivariate regression. Results Prevailing stigma in Singaporean society against LGBTQI+ individuals is exacerbated in healthcare settings. Doctors were cited as unfamiliar or uncomfortable with LGBTQI+ health, possibly from lack of training. Among medical students surveyed, the median composite attitudes, comfort and preparedness index was 3.30 (Interquartile Range (IQR) = 0.50), 3.17 (IQR = 0.83), 2.50 (IQR = 1.00) respectively. Only 12.19% of students answered all 11 true-false questions about LGBTQI+ health correctly. Conclusion Medical students in Singapore have scored sub-optimally in their knowledge and preparedness towards LGBTQI+ health, while interpersonal and structural stigma in healthcare towards LGBTQI+ people in Singapore negatively affects health and wellbeing. These findings are an impetus to improve medical training in this area. High scores among medical students in attitudes, comfort and perceived importance of LGBTQI+ topics demonstrate that there is space for LGBTQI+ health in the local medical education curriculum. Curricular interventions can prioritise content knowledge, communication skills and sensitivity.

Engaging Stigmatised Communities in Australia with Digital Health Systems: Towards Data Justice in Public Health

IntroductionIn 2018, following government policy changes to Australia’s national electronic health record system, ‘My Health Record’, consumer advocates—including organisations representing people living with HIV, people who use drugs and sex workers—raised concerns about privacy and data security. Responding to these controversies, this study explores the practical, ethical and political complexities of engaging stigmatised communities with digital health systems.MethodsWe conducted 16 qualitative semi-structured interviews in 2020 with key informants representing communities who experience stigma, discrimination and marginalisation in Australia. These communities included people living with HIV, sex workers, people who inject drugs, gay and bisexual men and transgender and gender diverse people. We conducted a reflexive thematic analysis.ResultsKey informants were sceptical of proposed benefits of electronic health records for their communities, and concerned about privacy risks and the potential for discrimination. Meaningful consultation, consent mechanisms and tackling structural stigma were raised as solutions for engaging communities.ConclusionsAlthough communities could benefit from being included in digital health systems, significant cultural, legal and social reforms from government were believed to be necessary to build trust in digital health systems. We argue that these forms of data justice are necessary for effective future systems.Policy ImplicationsEngaging stigmatised communities—including in relation to gender, sexuality, sex work, drug use, HIV—requires a commitment to data justice. The design and implementation of digital health systems requires investment in ongoing and meaningful consultation with communities and representative organisations.