Patterns of Post-Traumatic Health Care Service Need and Access among Bisexual and Non-Monosexual Women in the U.S

Coolhart D., Brown M.T.

Studies indicate LGBTQ youth are at higher risk of homelessness (2–13 times) than their heterosexual cisgender counterparts and that they represent a substantial portion of youth utilizing housing and shelter services. Some authors have provided anecdotal (rather than empirical) examples of LGBTQ youth experiencing abuse or mistreatment in shelters; most studies focusing on LGBTQ homeless youth have been conducted in large cities and have rarely collected data from both youth and providers. Using an exploratory, grounded theory approach, this study utilized data from interviews with LGBTQ youth with a history of homelessness as well as service providers working with this population in a mid-sized Northeastern city. Findings suggest youth experience multiple challenges, barriers, and mistreatment in the shelters; further, data suggests several ideas about how to transform shelters to better meet the needs of LGBTQ youth.

Coston B.M.

While just over one in three heterosexual women will experience intimate partner violence (IPV) in her lifetime, 61% of bisexual women and 78% of non-monosexual women will. Combining previous research and theories on power, social resources, binegativity, and gender-based violence, this article analyzes the role of power and inequality in non-monosexual women’s IPV victimization. Using data from the National Intimate Partner and Sexual Violence Survey, this article first examines rates of IPV victimization for statistically significant differences between monosexual (e.g., only have dating, romantic, and sexual partners of one sex/gender) and non-monosexual (e.g., have dating, romantic, and sexual partners of multiple sexes/genders) women in the United States and, second, introduces theoretically important variables to logistic regression analyses to determine the correlates of IPV victimization among non-monosexual women (age, race ethnicity, income, education, immigration status, and indigeneity; partner gender; sexual identity). Findings indicate that non-monosexual women are more likely to experience sexual, emotional, and psychological/control violence, and intimate stalking, but have an equivalent risk of experiencing physical violence. Moreover, having an abusive partner who is a man, having a lot of relative social power, and self-identifying as “bisexual” are all significant factors in violence victimization. Importantly, this is the first study using nationally representative data that confirms non-monosexual women are particularly at risk for sexual identity-based violence at the hands of their male/man partners, suggesting binegativity and biphobia may indeed be linked to hegemonic masculinity. Suggestions for moving research forward include improving data collection efforts such that we can disentangle gender from sex and individual aggregate power from relationship inequalities, as well as more adequately account for the timing of sexual identity disclosures within relationships, relative to the timing of violent episodes.

Turell S.C., Brown M., Herrmann M.

ABSTRACTIn 2010, the National Center for Injury Prevention and Control conducted the National Intimate Partner and Sexual Violence Survey. Their findings indicated that bisexual people, with some variance across gender identity, were more likely than any other sexual orientation to experience intimate partner violence (IPV). In keeping with these findings, this study conducted an exploratory analysis to explain these disparities, including the relationships between IPV and stereotypes about bisexuality and subscription to bi-negative attitudes, with a closer examination of relationship identity as monogamous or open; perceived infidelity in the relationship, given the prevalence of the stereotypes regarding promiscuity; and the complexity between the stereotype and the lived experience of polyamory or open relationships of many bisexual people. A convenience sample of bisexual people (n = 439) was solicited via Facebook groups and MTurk. Using path analyses, perpetrator bi-negativity and perceived or real...

Browne A.J.

Bailey Z.D., Krieger N., Agénor M., Graves J., Linos N., Bassett M.T.

Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.

Cahill S., Taylor S.W., Elsesser S.A., Mena L., Hickson D., Mayer K.H.

Gay and bisexual men and other men who have sex with men (MSM) account for more than two thirds of new HIV infections in the U.S., with Black MSM experiencing the greatest burden. Antiretroviral pre-exposure prophylaxis (PrEP) can reduce MSM's vulnerability to HIV infection. Uptake of PrEP has been limited, particularly among racial and ethnic minority MSM. Four semi-structured focus groups with gay and bisexual men and other MSM at risk for HIV infection were convened in Boston and Jackson in late 2013. The analysis plan utilized a within-case, across-case approach to code and analyze emerging themes, and to compare results across the two cities. Participants recruited in Jackson were primarily Black gay men, while Boston participants were mostly non-Hispanic White gay men. Participants in both sites shared concerns about medication side effects and culturally insensitive health care for gay men. Jackson participants described stronger medical mistrust, and more frequently described experiences of anti-gay and HIV related stigma. Multiple addressable barriers to PrEP uptake were described. Information about side effects should be explicitly addressed in PrEP education campaigns. Providers and health departments should address medical mistrust, especially among Black gay and bisexual men and other MSM, in part by training providers in how to provide affirming, culturally competent care. Medicaid should be expanded in Mississippi to cover low-income young Black gay and bisexual men and other MSM.

Carr B.G., Bowman A.J., Wolff C.S., Mullen M.T., Holena D.N., Branas C.C., Wiebe D.J.

Injury is a major contributor to morbidity and mortality in the United States. Accordingly, expanding access to trauma care is a Healthy People priority. The extent to which disparities in access to trauma care exist in the US is unknown. Our objective was to describe geographic, demographic, and socioeconomic disparities in access to trauma care in the United States.Cross-sectional study of the US population in 2010 using small units of geographic analysis and validated estimates of population access to a Level I or II trauma center within 60minutes via ambulance or helicopter. We examined the association between geographic, demographic, and socioeconomic factors and trauma center access, with subgroup analyses of urban-rural disparities.Of the 309 million people in the US in 2010, 29.7 million lacked access to trauma care. Across the country, areas with higher income were significantly more likely to have access (OR 1.30, 95% CI 1.12-1.50), as were major cities (OR 2.13, 95% CI 1.25-3.62) and suburbs (OR 1.27, 95% CI 1.02-1.57). Areas with higher rates of uninsured (OR 0.09, 95% CI 0.07-0.11) and Medicaid or Medicare eligible patients (OR 0.69, 95% CI 0.59-0.82) were less likely to have access. Areas with higher proportions of blacks and non-whites were more likely to have access (OR 1.37, 95% CI 1.19-1.58), as were areas with higher proportions of Hispanics and foreign-born persons (OR 1.51, 95% CI 1.13-2.01). Overall, rurality was associated with significantly lower access to trauma care (OR 0.20, 95% CI 0.18-0.23).While the majority of the United States has access to trauma care within an hour, almost 30 million US residents do not. Significant disparities in access were evident for vulnerable populations defined by insurance status, income, and rurality.

Osborn R., Squires D., Doty M.M., Sarnak D.O., Schneider E.C.

Surveys of patients' experiences with health care services can reveal how well a country's health system is meeting the needs of its population. Using data from a 2016 survey conducted in eleven countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-we found that US adults reported poor health and well-being and were the most likely to experience material hardship. The United States trailed other countries in making health care affordable and ranked poorly on providing timely access to medical care (except specialist care). In all countries, shortfalls in patient engagement and chronic care management were reported, and at least one in five adults experienced a care coordination problem. Problems were often particularly acute for low-income adults. Overall, the Netherlands performed at the top of the eleven-country range on most measures of access, engagement, and coordination.

Macapagal K., Bhatia R., Greene G.J.

Health services research involving lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) individuals has focused on differences in healthcare access, use, and experiences between cisgender, heterosexual adults and LGBTQ adults. Yet these factors may differ within the LGBTQ community and have not been well-studied among emerging adults (18-29 years), a group with unique barriers to healthcare. We sought to characterize healthcare challenges within a sample of LGBTQ emerging adults.From 2012 to 2013, 206 participants aged 18-27 (86% racial/ethnic minority, 10% transgender) completed questionnaires assessing healthcare access, use, and experiences during a longitudinal study. Descriptive statistics established patterns of healthcare access, use, and experiences, and nonparametric tests examined differences related to sociodemographic variables, HIV status, sexual orientation identity, and gender identity.Overall, 68% of participants reported relatively easy access to care. White and bisexual participants reported higher rates of insurance than racial/ethnic minority (P = 0.01) and gay or lesbian participants (P = 0.005), respectively. Although most participants did not report having negative experiences in healthcare settings related to their LGBTQ identity, transgender participants were more likely to delay care (P < 0.001) and report negative effects of disclosure to their provider (P < 0.001) compared with cisgender participants. Participants who identified as queer or were questioning their sexual orientation identity reported negative healthcare experiences more frequently than LGB-identified participants (P = 0.001).Although LGBTQ emerging adults experienced fewer barriers to care than observed in previous studies on LGBTQ adults, the results suggest that queer, questioning, and transgender individuals may face additional healthcare challenges compared with their LGB and cisgender counterparts.

Karliner L.S., Pérez-Stable E.J., Gregorich S.E.

Twenty-five million people in the United States have limited English proficiency (LEP); this growing and aging population experiences worse outcomes when hospitalized. Federal requirements that hospitals provide language access services are very challenging to implement in the fast-paced, 24-hour hospital environment.To determine if increasing access to professional interpreters improves hospital outcomes for older patients with LEP.Natural experiment on a medicine floor of an academic hospital.Patients age 50 years or above discharged between January 15, 2007 and January 15, 2010.Dual-handset interpreter telephone at every bedside July 15, 2008 to Mar 14, 2009.Thirty-day readmission, length of stay, estimated hospital expenditures.Of 8077 discharges, 1963 were for LEP, and 6114 for English proficient patients. There was a significant decrease in observed 30-day readmission rates for the LEP group during the 8-month intervention period compared with 18 months preintervention (17.8% vs. 13.4%); at the same time English proficient readmission rates increased (16.7% vs. 19.7%); results remained significant in adjusted analyses. This improved readmission outcome for the LEP group was not maintained during the subsequent postintervention period when the telephones became less accessible. There was no significant intervention impact on length of stay in either unadjusted or adjusted analyses. After accounting for interpreter services costs, the estimated 119 readmissions averted during the intervention period were associated with estimated monthly hospital expenditure savings of $161,404.Comprehensive language access represents an important, high value service that all medical centers should provide to achieve equitable, quality healthcare for vulnerable LEP populations.

Velez D., Palomo-Zerfas A., Nunez-Alvarez A., Ayala G.X., Finlayson T.L.

To qualitatively examine facilitators and barriers to dental care access and quality services among Mexican migrant women and their families living in North San Diego County, California. Six focus groups were conducted, with 52 participants. Three focus groups were with community residents (average group size of 10), and three were with community health workers/leaders (called Lideres; average group size of 7). The behavioral model for vulnerable populations theoretical framework guided qualitative data analyses. Predisposing factors to dental care access varied and included immigration status, language, and dental care experiences. Barriers to accessing quality dental services included high cost, lack of insurance coverage, dissatisfaction with providers, long wait times and discrimination. Participants expressed a desire for health policy changes, including affordable coverage for immigrants and their families. This study provided insights into how dental care providers, community health centers, and policymakers can improve dental care access and services to migrant populations.

Charest M., Kleinplatz P.J., Lund J.I.

Most studies on young adults' sources of sexual health information and confidence in sexual health practices have focused primarily on heterosexual university students. This study sought to bridge this gap in the literature by exploring where emerging adults, including LGBTQ+ individuals and those who do not pursue postsecondary education, obtain their sexuality information and how this relates to sexual self-efficacy. A total of 386 adults between the ages of 18 and 25 were divided into higher education (n=306) versus high school (n=80) groups and heterosexual (n=215) versus LGBTQ+ (n=171) emerging adults. Participants completed measures of sexual health information sources, as well as self-efficacy with regard to sexual health practices. Heterosexual participants obtained significantly more information from school/university courses and less from educational websites/news outlets than LGBTQ+ participants. Heterosexual participants were significantly more confident in their sexual health practices than LGBTQ+ participants. Different sources of information helped predict sexual self-efficacy across these four groups. Acquiring more information from significant others was the only significant predictor of sexual self-efficacy for all four groups. This study suggests that sexual health information should be discussed within a more relational or interpersonal framework, and that LGBTQ+ issues should be further incorporated and integrated in sex education curricula. Implications for healthcare providers, public health policy, sex educators, clinicians and future research are discussed.

Caldwell J.T., Ford C.L., Wallace S.P., Wang M.C., Takahashi L.M.

Objectives. To examine whether living in a rural versus urban area differentially exposes populations to social conditions associated with disparities in access to health care. Methods. We linked Medical Expenditure Panel Survey (2005–2010) data to geographic data from the American Community Survey (2005–2009) and Area Health Resource File (2010). We categorized census tracts as rural and urban by using the Rural–Urban Commuting Area Codes. Respondent sample sizes ranged from 49 839 to 105 306. Outcomes were access to a usual source of health care, cholesterol screening, cervical screening, dental visit within recommended intervals, and health care needs met. Results. African Americans in rural areas had lower odds of cholesterol screening (odds ratio[OR] = 0.37; 95% confidence interval[CI] = 0.25, 0.57) and cervical screening (OR = 0.48; 95% CI = 0.29, 0.80) than African Americans in urban areas. Whites had fewer screenings and dental visits in rural versus urban areas. There were mixed results for which racial/ethnic group had better access. Conclusions. Rural status confers additional disadvantage for most of the health care use measures, independently of poverty and health care supply.

Prather C., Fuller T.R., Marshall K.J., Jeffries W.L.

African American women are disproportionately affected by multiple sexual and reproductive health conditions compared with women of other races/ethnicities. Research suggests that social determinants of health, including poverty, unemployment, and limited education, contribute to health disparities. However, racism is a probable underlying determinant of these social conditions. This article uses a socioecological model to describe racism and its impact on African American women's sexual and reproductive health. Although similar models have been used for specific infectious and chronic diseases, they have not described how the historical underpinnings of racism affect current sexual and reproductive health outcomes among African American women. We propose a socioecological model that demonstrates how social determinants grounded in racism affect individual behaviors and interpersonal relationships, which may contribute to sexual and reproductive health outcomes. This model provides a perspective to understand how these unique contextual experiences are intertwined with the daily lived experiences of African American women and how they are potentially linked to poor sexual and reproductive health outcomes. The model also presents an opportunity to increase dialog and research among public health practitioners and encourages them to consider the role of these contextual experiences and supportive data when developing prevention interventions. Considerations address the provision of opportunities to promote health equity by reducing the effects of racism and improving African American women's sexual and reproductive health.

Genoff M.C., Zaballa A., Gany F., Gonzalez J., Ramirez J., Jewell S.T., Diamond L.C.

To systematically review the literature on the impact of patient navigators on cancer screening for limited English proficient (LEP) patients. Electronic databases (PubMed, PsycINFO via OVID, Web of Science, Cochrane, EMBASE, and Scopus) through 8 May 2015. Articles in this review had: (1) a study population of LEP patients eligible for breast, cervical or colorectal cancer screenings, (2) a patient navigator intervention to provide services prior to or during cancer screening, (3) a comparison of the patient navigator intervention to either a control group or another intervention, and (4) language-specific outcomes related to the patient navigator intervention. We assessed the quality of the articles using the Downs and Black Scale. Fifteen studies met the inclusion criteria and evaluated the screening rates for breast, colorectal, and cervical cancer in 15 language populations. Fourteen studies resulted in improved screening rates for LEP patients between 7 and 60 %. There was great variability in the patient navigation interventions evaluated. Training received by navigators was not reported in nine of the studies and no studies assessed the language skills of the patient navigators in English or the target language. This study is limited by the variability in study designs and limited reporting on patient navigator interventions, which reduces the ability to draw conclusions on the full effect of patient navigators. Overall, we found evidence that navigators improved screening rates for breast, cervical and colorectal cancer screening for LEP patients. Future studies should systematically collect data on the training curricula for navigators and assess their English and non-English language skills in order to identify ways to reduce disparities for LEP patients.

McCauley H.L., Reid T.A., Anderson R.E., Ast R., Zelazny S., Miller E.

Sexual minoritized women (SMW) are more likely than exclusively heterosexual women to experience intimate partner violence (IPV). We conducted in-depth interviews with a clinic-based sample of plurisexual SMW ( n = 25) ages 18 to 34 about the gender of their perpetrators. Participants primarily experienced physical and sexual IPV in relationships with men and emotional abuse in relationships with women. IPV perpetrated by men often included weapons with women fearing for their lives. Offering patients information about IPV resources and supports that do not make assumptions about women's sexualities may create more opportunity for empathic and effective communication with SMW experiencing IPV.

Porsch L.M., Xu M., Veldhuis C.B., Bochicchio L.A., Zollweg S.S., Hughes T.L.

Intimate partner violence (IPV) is prevalent among sexual minority women (SMW). However, compared to IPV research with heterosexual women and other LGBTQ+ population groups, SMW are understudied. We conducted a scoping review to examine the current state of knowledge about IPV among SMW, and to identify gaps and directions for future research. A search of Medline, Embase, CINAHL, and PsycINFO databases returned 1,807 papers published between January 2000 and December 2021. After independent reviewers screened these papers for relevance, 99 were included in the final review. Papers were included if they used quantitative methods and reported IPV data on adult SMW separately from other groups. Findings confirmed high rates of IPV among SMW and highlighted groups with particular vulnerabilities, including non-monosexual women and SMW of color. Risk factors for IPV in this population include prior trauma and victimization, psychological and emotional concerns, substance use, and minority stressors. Outcomes include poor mental and physical health. Findings related to the effects of minority stressors on IPV and comparisons across sexual minority groups were inconsistent. Future research should focus on IPV perpetration; mechanisms underlying risk for IPV, including structural-level risk factors; and understanding differences among SMW subgroups.

Santoniccolo F., Trombetta T., Rollè L.

Same-Sex Intimate Partner Violence (SSIPV) is a complex issue that can be severely damaging. When involved in SSIPV, victims and perpetrators sometimes choose to seek help. The help-seeking process, however, can be difficult. Experiences of help-seeking seem to vary and may be positive or negative depending on several factors, some of which appear to be specific to lesbian, gay, and bisexual (LGB) people involved in a same-sex relationship. A systematic review of the literature has been conducted across four databases following the PRISMA statement guidelines. Out of 410 screened abstracts, 78 articles were selected for full-text review. Following the inclusion and exclusion criteria, 21 studies were included in the current review. Thematic analysis was conducted on these studies and results were discussed by three reviewers. Help-seekers tended to use informal sources of help, perceived to be ambivalently helpful. Formal sources tended to be utilized sparingly, except for counselors. Many formal sources were perceived to be unhelpful, and most of the studies identified several barriers to services that prevented effective help. Formal and helpful sources were perceived as knowledgeable and sensitive about LGB themes. While existing research is limited, formal services that can provide effective care for SSIPV appear scarce. Barriers to services seem widespread, limiting accessibility. Existing services would benefit from increasing their knowledge and sensitivity on SSIPV-specific themes. The development of policies, programs, and interventions that aim to provide effective help is needed, as well as more research.

Dickerson-Amaya N., Coston B.M.

Intimate partner violence (IPV) is a critical public health problem. However, there is limited research conducted on and about men who are survivors. This project extends previous research by examining the post-traumatic impact of diverse forms of IPV (sexual, physical, emotional, control, and stalking) on the internalized and externalized mental health of gay, bisexual, and straight men. Using data from the National Intimate Partner and Sexual Violence Survey (2011; N = 18,957), we find that all men are equally likely to report emotional victimization and controlling tactics (with between 50% and 70% doing so), while bisexual men are significantly more likely to report physical and sexual violence and gay men are significantly more likely to report intimate stalking. Due to these experiences, gay men are significantly more likely to report missing school or work, but bisexual men are significantly more likely to rate their current overall mental health as poor. Around 10% of all men, regardless of sexual orientation, report post-traumatic stress disorder symptomology and 30% of all men report difficulty sleeping. This research suggests that sexual orientation is a critical area of focus in the study of violence and mental health for men and that we can no longer ignore the voices and needs of men survivors: Invisibility is not invincibility.