Policy, Practice and People: Current Issues Affecting Clinical Practice

This commentary highlights current policy issues affecting lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in the US with implications for mental and behavioral health care and social work services. These issues include conversion or reparative therapies, especially for young people, and conscience clauses that may exempt some students and practitioners from serving LGBTQ people and their families. While not a “policy” per se, emerging knowledge about health disparities that affect LGBTQ people will also be summarized because of its relevance to practice; many of these concern mental health and behavioral health. Finally, some resources for making health care organizations more responsive to the needs of LGBT people are identified.     

Methodological Issues in Conducting Community-Based Health and Social Services Research Among Urban Black and African American LGBT Populations

Abstract

Health and social service utilization experiences of disenfranchised groups have recently gained renewed public attention. Reducing and eliminating racial disparities in health care has become a major national agenda. While a fairly substantial literature on Black and African American health outcomes and social service utilization does exist, and may help to influence interventions to reduce disparities, there is no comparable literature for Black and African American lesbian, gay, bisexual, and transgender (LGBT) persons. In this article the author examines factors affecting research with urban Black and African American LGBT populations. A brief case study is included that demonstrates the viability of the recommended research methods and discusses the possible negative consequences of deviating from these methodological suggestions.     

Lessons on social and health disparities from older lesbians with alcoholism and the role of interventions to promote culturally competent services

ABSTRACT

Older adults who are lesbian, gay, bisexual, or transgender (LGBT) face greater health risks and possibly more costly care because of their reluctance to seek out health and long-term care services because of limited cultural sensitivity of service providers. This is particularly evident in older lesbians who face substantial risk of health problems associated with alcoholism and are less likely to be open with health care providers because of stigma combined with feelings of alienation, stress, and depression. An estimated 4.4 million older adults are predicted to have problems with alcohol by 2020, and the rates of alcohol-related hospitalizations are similar to those for heart attacks, creating exorbitant medical costs. More culturally competent health and long-term care may reduce health care costs by effectively addressing the dynamics of alcoholism, aging, and lesbian culture. Training initiatives such as those developed by the National Resource Center on LGBT Aging have begun to address the need of a more culturally competent aging services network. This article provides exemplars from empirical data on older lesbians with alcoholism to highlight some of the health, economic, and social disparities experienced in the aging LGBT community. Current interventions in the form of cultural competence training for service providers are presented as a potential step toward addressing health disparities among LGBT older adults.     

Examining Associations Between Discrimination,Social Cohesion,and Health among White LGBT versus POC LGBT Chicagoans

Consistent with the minority stress perspective, lesbian/gay, bisexual, and transgender (LGBT) individuals on average report worse health than heterosexual individuals in several domains, for example, general health, mental health, physical health, and healthcare access. Intersectionality-based research shows that LGBT people of color (POC) are, on average, at even greater risk for adverse health outcomes. Discrimination and social cohesion may be two mechanisms underlying these between- and within-group disparities, given that both constructs are frequently reported within marginalized populations, and that both broadly relate to health. This study used data from the Chicago Department of Public Health to examine broad health differences between White LGBT and LGBT POC, and to test specific models in which social cohesion mediated links between discrimination and health. LGBT POC reported experiencing worse general health, lower access to health care, more experiences of discrimination, and lower feelings of social cohesion than did White LGBT individuals. No mediation effects emerged; however, there was a direct effect of experiencing discrimination on mental health distress. Discrimination exposure inversely related to the feelings of social cohesion.     

Sexual agency,risk and vulnerability: a scoping review of young Indigenous Australians’ sexual health

This review of qualitative research examining young Indigenous Australians’ sexual health highlights the profoundly social nature of young people’s sexual lives. Nineteen peer reviewed published papers were identified for inclusion. Findings reveal efforts made by some young Indigenous Australians to control their sexual lives, mitigate risk and maintain their sexual health. The review identified factors which are conducive to sexual health risks and vulnerability, including incomplete knowledge about STIs and safer sexual practices; gossip and ridicule concerning sexual activity and its consequences; damaging expectations about male prerogatives with respect to sexual relationships; limited inter-generational communication about sexual health issues; inadequate school-based sexual health education; and tensions between Indigenous and biomedical explanations of sexual health issues. Future research priorities include a focus on young Indigenous people in cities and towns across Australia, and in regional and remote settings in New South Wales and Victoria; understanding how Indigenous cultural values support young people’s sexual health; young men’s sexual and service-based practices; and the experiences of same-sex attracted and gender diverse youth. This research would inform the design and delivery of culturally safe and acceptable sexual health services and programmes, underpinned by an understanding of factors in young Indigenous Australians’ everyday sexual lives.     

“We Have to Create Family”: Aging Support Issues and Needs Among Older Lesbians

Gay and lesbian seniors are more likely to be single, live alone, and be childless. The current evidence base suggests that limited social supports are associated with a variety of health disparities among all older adults. Research regarding the aging issues of lesbian seniors is scarce. This instrumental collective case study of 4 older lesbians (ages 59 and older) illustrates unique aging support concerns, issues, and needs. The purpose of the case study is to increase provider sensitivity and provide supportive evidence of the need for more research. Findings suggest that limited biological family support, childlessness, and “families of choice” may be important factors in support service and health care decisions for older lesbians. Implications for care providers in working with the older lesbian population include exploring existing supports and assisting with the formation of culturally acceptable support systems and services. Given the current evidence base regarding the impact of social support on elder health, it is critical for providers to have a better understanding of elder lesbians’ unique concerns and needs relating to support and health care services in order to prevent health disparities among this vulnerable population.     

Youth voice in service acceptability: Experiences of lesbian,gay, bisexual,and transgender adolescents

This study engaged lesbian, gay, bisexual, and transgender (LGBT) youths to tell their stories of satisfying and dissatisfying HIV-related service features and tapped into their common language when expressing satisfaction. Findings included youth agreement with six of the nine features proposed by adult experts and identification of “atmosphere,” the service feature encompassing the youths’ need to be themselves, to find comfort, and to socialize. Inclusion of youth voice in the design of a satisfaction survey highlighted those features most meaningful to these LGBT youths and added to the growing literature regarding power sharing with youths in health services evaluation.     

Medicaid Managed Care Programs for High-Risk Older People in Massachusetts

The Commonwealth of Massachusetts has undertaken a major initiative in the development of comprehensive managed health care programs for two sets of high-risk older people: those who are frail and homebound and those who reside in nursing homes. This effort has been coordinated by the state's Department of Public Welfare (DPW; Medical Assistance [Medicaid] Program) and Executive Office of Elder Affairs, and expedited ba a set of Health Care Financy Administration (HCFA) waivers and by the state's revised Nurse Practice Act (MGS Chapter 56). Than act allows nurse-practioners and physician assistants expanded roles as primary providers in home care and nursing home settings. The managed care initiatives have supplemented other efforts (1) to coordinate health and social services for older people, (2) to provide as broad a range as possible of community-based services for older people, and (3) to enroll as many older adults as possible in Health Maintenance Organization (HMO) "Senior Plans" and other similar "Competive Medical Plans."

Though there is still no evidence of the managed care programs' effects, this article summarizes some of the possible risks and benefits of managed care programs for those kinds of populations and presents an agenda of questions that evaluations of managed care programs must address.     

A Community's Perceptions of Pediatric Social Outcomes in a Downsized Urban Hospital System

This article describes parental perceptions of pediatric services at Los Angeles County King/Drew Hospital and Medical Center after the hospital and its community clinics were restructured in the 1990s. Qualitative and quantitative measures are used to capture parental perceptions of service utilization, service convenience, and quality of care. The results are compared to hospital institutional operational data from patient flow analysis reports, appointment delay reports, and improving organizational performance committee reports. A comparison of parental perceptions of pediatric care is also made with findings from other post-devolution studies on access and quality of care at the Los Angeles County Department of Health Services. The implications of the findings for hospital quality assurance processes and health services outcomes research are discussed.     

Planning minority health programs to eliminate health status disparity

The purpose of this research is to determine program characteristics that are essential to address the problem of health status disparity between minority and nonminority populations. The respondent group consisted of a sample of 50 minority health organizations currently listed as participants in the Minority Health Resource Network in the United States Public Health Service Office of Minority Health. A three-round Delphi technique was used to reach consensus by collecting data and assessing agreement and disagreement on the issue of health status disparity from a widespread national group. Findings indicate that there is strong consensus among respondents that cultural awareness is the top priority area to address in order to eliminate health status disparities.     

The Perspectives of Young Men and Their Teenage Partners on Maternity and Health Services During Pregnancy and Early Parenthood

This study discusses young couples’ interactions with maternity and health services paying particular attention to men’s perspectives. Findings are based on research conducted in Scotland with men (aged 16–25) and their teenage partners (aged 16–19). Most young men were very involved in their child’s life and provided support and care to their partner during pregnancy and in early parenthood. Men often felt excluded or judged when accessing services, although positive experiences were reported too. The study discusses ways in which maternity and health services can be better attuned to meet the needs of young couples and be inclusive of men.     

Inequities in health outcomes and access to health care in South Africa: a comparison between persons with and without disabilities

Health is a fundamental human right and if health care is to be universal and equitable it should not be less accessible to some sectors of society than to others. The objective of this study was to compare health outcomes and access to health care between persons living with disabilities and their non-disabled counterparts. The research was based on secondary data analysis of wave 1 of the National Income Dynamic Survey. Results from the study indicated that people with disabilities reported a higher incidence of communicable and non-communicable diseases, lower access to medical insurance and greater use of public health care than their non-disabled counterparts. In conclusion, the findings highlight the inequities in health outcomes and access to health services for people with disabilities and emphasise the need for disability-friendly health care policies that reduce barriers to accessing health care.     

Health care,social care or both? A qualitative explorative study of different focuses in long-term care of older people in France,Portugal and Sweden

Challenges with an ageing population are increasingly becoming a reality in the Western world. Since cognitive impairment increases with age, we can expect an increasing number of older people in need of care. The aim of this article is to describe, analyse and compare different focuses on care of older people with dementia, using examples from France, Portugal and Sweden. The questions are principally focused on the participants’ view about their tasks, the organisation of work, the professional role and cooperation with other professions. Everyday care was studied through observations and participant observations and the staff's opinion was explored by means of interviews. Twenty-two care settings for older people were included. The findings showed that France provided mainly ‘health care’, Sweden ‘social care’ and Portugal an integrated ‘health care and social care’. In a comparative perspective the Portuguese general care of older people, which focuses on integration of health care, social care and social work, also seems to provide care for older people suffering from dementia which best corresponds to the previously developed group living model.     

Young African American Males: Barriers to Access to Health Care

African American males continue to experience an unacceptable and disproportionate number of health disparities when compared with other racial and ethnic groups. Young African American males can expect to live the least amount of time when compared to any other ethnic minority or racial sub-group. Understanding the obstacles and barriers that impede access to health care and wellness services among young African American males is essential to begin the process of decreasing health disparities. The goal of this qualitative study was to explore and identify the barriers experienced by young African American males in accessing health care services while also creating a rare opportunity to give voice to young African American males. The study results indicate that young African American males have multiple perceptions of barriers to health care services. Their perceptions fell into three categories: the negative impact of environment or community, lack of finances or no insurance, and distrust of medical practices associated with race history resulting in accessing healthcare as a last resort. Additional research is needed to craft community-based programs to: a) educate young African American males on the importance of preventative strategies to maintain wellness; and b) ensure that the appropriate medical and wellness services are available and reaching young African American males in need.     

Demographic study on Occupational Therapy Work Rehabilitation Programs in Hong Kong Hospital Authority

A survey was implemented to collect demographic data of Occupational Therapy Work Rehabilitation Programs in the Hong Kong Hospital Authority in order to reflect the patterns of services delivery within the largest health care organization in Hong Kong. The questionnaire covered types of settings, services provided, instruments/equipment used, sources and aims of referrals, types of patient, training programs attended by occupational therapists, staffing and research. The results of this survey demonstrated that there has been a significant development of the Occupational Therapy Work Rehabilitation Programs in Hong Kong Hospital Authority in the last decade. Future directions for further development are also identified.     

The relationship between medical education and trans health disparities: a call to research

According to the National Transgender Discrimination Survey, 28% of trans respondents reported postponing medical care due to discrimination, and 28% reported being harassed by providers when they did seek out care. Scholars have proposed that what is taught (or not) in medical schools might play a role in the unequal health care experienced by many trans people. As medical education becomes a site of intervention for reducing transgender health disparities, it presents opportunities for sociologists to study and explain the processes by which medical training creates, reinforces, and potentially challenges stigma‐related health disparities. In this paper, we propose three areas of inquiry that might help explain this situation: the hidden curriculum, patient health movements and consumerism, and medical competency. By employing these concepts, we argue that sociologists can develop more comprehensive explanations for the relationship between medical education and transgender health inequalities and offer solutions to address this disparity.     

Perceptions of transition-related health and mental health services among transgender adults

The opportunity to live authentically is critical for the well-being of transgender individuals. For many this requires accessing transition-related services. Current knowledge of transition-related care is limited. This study aims to elucidate experiences and needs of transgender individuals (N = 65) related to (a) therapeutic support, (b) medical care, and (c) aspects of living authentically in order to inform the development and delivery of trans-affirmative services. Findings reveal challenges accessing health care providers with trans-specific competency; gaps between critical aspects of transition-related care and receipt of services; and heterogeneity of experiences and needs. Recommendations for improving transgender-affirmative services are provided.     

Evaluating a community based mental health programme in West Bengal,India: Description of the methodology and lessons learned

Mental disorders impose an enormous burden on society. In developing countries like India, there is a lack of adequate number of trained mental health professionals to provide specialized care and 75–85 % of affected individuals do not have access to appropriate mental health services. The National Mental Health Programme (NMHP) is being implemented by the Government of India to support state governments in providing mental health services in the country. The Urban Mental Health Programme (UMHP) is a pilot initiative that has attempted the integration of mental health services in primary health care settings in two municipal wards in Kolkata, West Bengal, India. The overarching aim of this paper is to describe the methodology used for the evaluation of the community based mental health programme and to understand the processes of the programme in terms of barriers and facilitators. The current evaluation is based on a concurrent nested design, where qualitative and quantitative data are both collected at the same time but analysed separately and priority was given to qualitative data. This experience will contribute in helping other researchers to make some evaluations more effective, useful and manageable. Ethics approval was obtained from an institutional ethics committee of an organization (Ekjut) based in Ranchi, Jharkhand, India. The evaluation was undertaken by the George Institute for Global Health, New Delhi from February- June 2016.     

Promoting resilience and emotional well-being of transgender young people: research at the intersections of gender and sexuality

Within lesbian, gay, bisexual and transgender (LGBT) research there is increasing health-related scholarship on trans lives, with a growing awareness of the impact of health inequalities on trans well-being. The aim of the paper is to provide greater understanding of transgender young people’s views of what is needed to promote their emotional well-being and resilience by undertaking specific analysis of data collected as part of wider research with young people (n?=?97). The study utilised participatory qualitative methods with a cross sectional design generating data via a focus group with trans youth (n?=?5), followed by thematic analysis. Findings suggest that both individual and collective capacities or resources enable and sustain resilience and well-being for trans young people. The adversity trans youth face is present in school, the community and in healthcare, but they are able to find places where they feel safe and connected to others. Practitioners, teachers and school nurses are well positioned to facilitate structural change in alliance with trans youth to promote resilience. Research results were utilised to inform health improvement, commissioning and service delivery.