Promoting Equitable Sexual Health Communication among Patients with Minoritized Racial/Ethnic, Sexual Orientation, and Gender Identities: Strategies, Challenges, and Opportunities

Abstract

People assigned female at birth (AFAB) with minoritized racial/ethnic, sexual orientation, and gender identities experience notable barriers to high-quality sexual healthcare. In confronting these barriers, patient-provider communication can be a crucial factor, influencing patients’ experiences and access to relevant sexual health information and services by determining the quality of care. However, research that investigates this communication among AFAB patients with minoritized social positions is scarce, indicating a research gap regarding the perspectives and roles of healthcare providers in addressing such barriers to care for minoritized patients. Thus, we conducted a qualitative research study, using individual in-depth interviews, to explore the multi-level factors that influence providers’ attitudes, knowledge, and skills regarding sexual health communication with AFAB patients with minoritized racial/ethnic, sexual orientation, and gender identities. Interpreting study findings within frameworks of person-centered care, intersectionality, and structural competency, we identified three cross-cutting themes. We found that providers frequently drew on their prior professional training, personal lived experiences, and population-level health disparities data when engaging in sexual health communication with minoritized AFAB patients. Participants reported minimal explicit training in anti-racist and lesbian, gay, bisexual, transgender, and queer (LGBTQ+)-competent care as a significant barrier to engaging in equitable sexual health communication with minoritized AFAB patients, which was exacerbated by many providers’ lack of shared social positions and lived experiences with these patients. Providers also frequently applied population-level data to individual patients when formulating counseling and recommendations, which may undermine person-centered sexual health communication. Our findings suggest that critical anti-racist and LGBTQ+-competent provider training is urgently needed, and that health professional education and institutions must be transformed to better reflect and consider the experiences of patients with minoritized racial/ethnic, sexual orientation, and gender identities.

1. INTRODUCTION

Timely access to high-quality sexual healthcare, including human papillomavirus (HPV) vaccination, contraception, sexually transmitted infection (STI) testing, and cervical cancer screening, is critical for well-being among cisgender women, transgender men, and nonbinary people who were assigned female at birth (AFAB) (Agénor et al., 2021; Baker et al., 2021; Douglas & Fenton, 2013; KFF, 2018). However, researchers have identified pronounced barriers to sexual healthcare among AFAB individuals with minoritized racial/ethnic, sexual orientation, and gender identities, despite the disproportionate burden of poor sexual health outcomes in these groups (Agénor et al., 2021; Baker et al., 2021; Cohn & Harrison, 2022; Prather et al., 2018; Sutton et al., 2021). For example, although Black and Latina women experience higher levels of unintended pregnancy and cervical cancer, some studies indicate that they are less likely to obtain contraceptive care and initiate HPV vaccination relative to White women (Beroukhim et al., 2022; Haider et al., 2013). Additionally, Asian-American women experience one of the highest rates of cervical cancer incidence and mortality, in addition to lower rates of HPV vaccination and health literacy compared to non-Latina White women (Lee et al., 2015). Studies indicate that such racial/ethnic inequities are driven by structural factors rooted in gendered racism, including lack of access to health insurance and socioeconomic resources, residential segregation, historical medical mistrust, and healthcare provider bias toward women of color (Rosenthal & Lobel, 2020; Sutton et al., 2021; Thompson et al., 2022). High-quality sexual healthcare can be assessed within a person-centered framework, which emphasizes care that is tailored to the unique background, needs, and contexts of each patient (Morgan & Yoder, 2012).

Sexually minoritized women (SMW), including lesbian and bisexual women, also experience notable barriers to high-quality sexual healthcare due to lack of access to health insurance, challenges identifying LGBTQ+-competent healthcare providers, and limited access to relevant sexual health information — factors rooted in interpersonal, institutional, and structural heterosexism (Beroukhim et al., 2022; Haider et al., 2013). Although women with only female sexual partners can acquire STIs and develop cervical cancer, they are often erroneously perceived to be at no or negligible risk — which in turn undermines their utilization of HPV vaccination, STI testing, and cervical cancer screening (Agénor et al., 2019; Jahn et al., 2019). Transgender men and nonbinary AFAB people also report barriers to affirming sexual healthcare information and services due to providers’ limited knowledge on gender minority health, gender-related discrimination in clinical settings, and the scarcity of tailored sexual health information (Harb et al., 2019). Additionally, transgender men and non-binary AFAB people must often seek care in highly gendered, exclusionary clinical environments where services such as contraception and Pap testing are characterized as “women’s” issues (Seelman & Poteat, 2020). Health inequities impacting minoritized patients can be assessed within the framework of person-centered care, an approach which aims to center each individual patient’s needs and preferences in clinical decision-making spaces, emphasizing a holistic understanding of the patient as a person with unique backgrounds and values (Morgan & Yoder, 2012). Indeed, as conceptualized within a framework of person-centered care, SMW, transgender men, and nonbinary AFAB people often experience challenges to seeking and receiving care that is uniquely attuned to their sexual and reproductive health needs and that incorporates LGBTQ+-affirming values.

Furthermore, studies indicate that LGBTQ+ people of color experience particularly pronounced barriers to high-quality sexual health services, resulting from compounding effects of racism, sexism, heterosexism, and cisgenderism at interpersonal, institutional, and structural levels (Agénor et al., 2015; Smart et al., 2022). These barriers can be understood within an intersectionality framework that recognizes the compounding social inequities impacting minoritized patients, who in turn experience increasingly pronounced challenges to seeking and receiving high-quality, person-centered care (Samra & Hankivsky, 2021; Wilson et al., 2019).

Sexual health communication plays a key role in shaping the experiences of AFAB individuals with minoritized racial/ethnic, sexual orientation, and gender identities, including by influencing patient comfort, trust, and access to relevant health information (Agénor et al., 2015; Jahn et al., 2019; Tabaac et al., 2022). To date, research has primarily focused on patients’ perspectives, despite the bidirectional nature of patient-provider communication wherein providers’ beliefs, assumptions, and personal and professional characteristics can greatly impact patients’ experiences (Agénor et al., 2015; Calabrese et al., 2022; Tabaac et al., 2022) To address this research gap, we conducted a qualitative research study to explore providers’ knowledge, attitudes, and skills related to engaging in sexual health communication with AFAB patients with minoritized racial/ethnic, sexual orientation, and gender identities, and elucidate the influences of individual, institutional, and structural factors. Notably, we aimed to interpret the implications of our study findings in light of a structural competency framework, which elucidates the higher-level structural factors in healthcare systems and broader society that impact clinical care beyond individual provider behavior, such as organizational and institutional policies in addition to structural forces outside of healthcare systems (Metzl & Hansen, 2014).

2. METHODS

2.1. Sampling and Recruitment

We recruited 30 healthcare providers in Massachusetts and Rhode Island, whose sociodemographic and professional characteristics are presented in Table 1, for online in-depth interviews. We used a purposive sampling approach with the following eligibility criteria: working as a physician, physician assistant (PA), or nurse practitioner (NP); practicing in a non-emergency setting at a healthcare facility (e.g., clinic, community health center, private office, hospital); providing care to people ages 18 years and older; and provided an HPV vaccine and/or administered a Pap test in the past year. Participants were recruited through our professional networks at community health centers, clinics, and hospitals in Massachusetts and Rhode Island, and using snowball sampling (Arcury & Quandt, 1999). We asked professional colleagues if they were interested in participating in our study and were able to share the study information with their colleagues. We initially contacted 23 people directly about the study. Nine were healthcare providers and researchers from our professional network who had expertise in LGBTQ+ health, sexual and reproductive health, and health equity, who were not invited to participate in our study but were asked to help share study information. The remaining 14 individuals were healthcare providers, also in our professional network, who were asked to both participate and share information on our study; two of these providers enrolled as participants. The remaining participants (N=28) were recruited through snowball sampling. We aimed to achieve data saturation in relation to the study’s research question regarding provider knowledge, attitudes, and skills related to cervical cancer prevention among AFAB patients with minoritized racial/ethnic, sexual orientation, and gender identities (Saunders et al., 2018).

Table 1.

Healthcare provider sociodemographic and professional characteristics (N=30)

Characteristic	n	%
Sex Assigned at Birth
Female	28	93%
Male	2	7%
Gender Identity*
Cisgender Man	2	7%
Cisgender Woman	28	93%
Nonbinary	0	0%
Race/Ethnicity*
Asian/Asian American or Pacific Islander	6	20%
Black or African American	4	13%
Latinx or Hispanic	2	7%
White	20	67%
Multiracial	1	3%
Sexual Orientation Identity*
Heterosexual	24	80%
Lesbian or Gay	3	10%
Bisexual	3	10%
Queer	4	13%
Location of Practice
Massachusetts	25	83%
Rhode Island	5	17%
Healthcare Setting of Practice
Clinic	11	37%
Community Health Center	8	27%
Hospital	10	33%
Private Practice	1	3%
Geographic Setting of Practice
Suburban	3	10%
Urban	27	90%
Rural	0	0%
Profession
Nurse Practitioner	8	27%
Physician (MD or DO)	14	47%
Physician Assistant	8	27%

Note. Percentages may not add to 100% due to rounding.

^*Participants could check all that apply

2.2. Data Collection

Interviews for our descriptive qualitative study were conducted on Zoom in June and July 2020 and lasted ~60 minutes. Participants provided verbal informed consent and completed a demographic survey before beginning the interview. Interviews were conducted by three cisgender women interviewers from diverse racial/ethnic backgrounds (Black, Asian, and White). One interviewer was a faculty member, and two interviewers were Research Assistants who had undergone interviewing training and who had prior experience in qualitative research and public health. Interviewers used a semi-structured interview guide with open-ended questions informed by the scientific literature on clinical decision-making, cervical cancer screening disparities, and provider- and institutional-level barriers to and facilitators of cervical cancer screening among minoritized patients. The guide was reviewed by experts in sexual and gender minority (SGM) health and addressed the following topics: providers’ previous training experiences in racial/ethnic health equity and SGM health, approaches to sexual history taking, and sexual health communication and services delivery among AFAB patients with diverse racial/ethnic, sexual orientation, and gender identities. Participants received a $100 gift card for their time. All research activities were approved by the Social, Behavioral, and Educational Research IRB at Tufts University (Protocol # IRB00009494).

2.3. Data Analysis

Interview audio recordings were transcribed verbatim by a professional transcription company and uploaded to NVivo software to facilitate qualitative data analysis. The first author used a hybrid hierarchical template analysis approach with deductive and inductive coding to develop themes and subthemes pertaining to patient-provider sexual health communication and its multilevel social determinants (Crabtree & Miller, 2022; Fereday & Muir-Cochrane, 2006). Specifically, the first author developed an initial codebook comprised of both deductive codes based on the interview guide and scientific literature and inductive codes from the interview transcripts. She then applied the initial codebook to four transcripts, iteratively revising and refining the codebook, including the hierarchical structure, as needed to improve its fit to the data, while discussing these steps with the senior author (Brooks et al., 2015; Crabtree & Miller, 1992, 2022; Fereday & Muir-Cochrane, 2006). Next, she produced code summaries and wrote coding memos. Coded excerpts were then clustered into themes and sub-themes developed across a range of deductive and inductive codes using memos, diagrams, and a data analysis matrix, which facilitated theme development and refinement as well as comparisons among participants based on their professional background, race/ethnicity, and sexual orientation (Birks et al., 2008; Crabtree & Miller, 1992, 2022; Fereday & Muir-Cochrane, 2006; Miles et al., 2014). The first author held meetings at regular intervals with the senior author to discuss analysis as it progressed in terms of codebook development, application of codes to transcripts, theme and sub-theme development, and final interpretations of the data to enhance validity of study results (King et al., 2019).

3. RESULTS

3.1. Theme 1. Gaps in training on health disparities can undermine sexual health communication with minoritized patients.

3.1.1. Most providers have received minimal explicit training in racial/ethnic and LGBTQ+ health equity.

While a few providers were able to name substantive training opportunities related to minoritized patients’ health, the majority commented that they received minimal explicit training on racial/ethnic disparities, including pertaining to sexual healthcare. Training was frequently described as packaged into discrete modules or lectures, but there was limited widespread, in-depth training on racial/ethnic disparities and their relation to sexual health. When asked about prior training on racial/ethnic disparities, a White, heterosexual, cisgender woman nurse practitioner (NP) at an urban hospital-affiliated clinic commented: “Yeah, the fact that I can’t come up with anything is alarming. Again, I think we probably had a lecture or something or it was minimally incorporated.” A White, heterosexual, cisgender woman resident physician at an urban hospital described: “We’ve had very limited formal training or formal didactics, I would say, on health disparities. I think occasionally there will be grand rounds maybe once or twice a year … But in terms of formal training, it’s been pretty limited.” A White, queer, cisgender woman NP at an urban hospital described that among providers, inadequate focus on the roots of racial/ethnic disparities contributes to reductionist perceptions of health disparities: “We are told, for example, Black men are at increased risk of high blood pressure and blood disease. It becomes a pathology rather than actually getting down to the nitty-gritty of public health.”

3.1.2. Providers express a lack of comfort toward communicating about sexual healthcare with minoritized patients.

Providers who received minimal explicit training on racial/ethnic issues described feeling insufficiently knowledgeable about strategies to help mediate the consequences of these inequities as they present for patients. A White, heterosexual, cisgender woman resident physician at an urban hospital stated: “I think it’s been really lacking throughout residency — and even before residency in medical school. I feel like there has been very little to equip us in terms of what we can do as providers to help address some of these inequities.” When asked about her comfort with providing preventive services to patients at higher risk for cervical cancer by race/ethnicity, a White, heterosexual, cisgender woman NP at an urban hospital-affiliated clinic replied: “I feel unsatisfied now, because I think that this has been eye-opening for me in realizing … how many aspects of my clinical education — not that it was poor, but there were a lot of things missing that I would have liked, and I think that this is one of them.”

In terms of sexual orientation, a large proportion of providers expressed lack of confidence in adequately communicating with SMW patients compared to other LGBTQ+ populations. Formal training opportunities on sexual minority health were frequently relegated to opt-in or one-off modules or workshops. A White, heterosexual, cisgender woman resident physician at an urban hospital stated: “As a medical student, we had probably a one-time lecture in our ‘Learning to be a Doctor’ course about care of the LGBTQ patient, but that was so long ago and it certainly wasn’t specific to my field in OB/GYN.” SMW’s health was also frequently recognized as particularly lacking in training compared to broader LGBTQ+ healthcare. Subsequently, some providers felt inadequately prepared to comprehensively address issues experienced by SMW. One White, heterosexual, cisgender woman PA at an urban clinic commented: “I don’t know anything about if they [SMW] want to have a baby, that stuff. Like fertility and stuff.” Providers commented that when formal training opportunities on sexual minority health were scarce, the onus was frequently placed on providers to seek out education, including through their colleagues. A Black, bisexual, cisgender woman PA at an urban community health center described: “I feel like I haven’t really had any good training in LGBTQ health. I have had patients who have had depression and anxiety or who are going through transition. And I feel like when those questions come up, you know, we’re always asking other providers and like what do they know.”

In terms of patients with minoritized gender identities, some providers expressed discomfort toward confidently communicating in these areas, despite some prior training. An Asian, heterosexual, cisgender woman PA at an urban clinic first described some prior training on transgender and non-binary care: “We had a day on transgender medicine and specifically we talked a lot about cancer screenings for transgender patients. [...] I think we had a topic on intersex patients at birth and the sort of controversy around infant gender assignment surgeries. So that was pretty specific.” She then proceeded to describe still feeling dissatisfied with her level of knowledge considering the low number of transgender and non-binary patients she sees: “And then I would say probably transgender medicine is the thing that I feel maybe the least comfortable with just because I haven’t seen a lot of trans patients.”

A White, heterosexual, cisgender woman PA at an urban community health center echoed a lack of preparation when asked about providing cervical cancer prevention services to minoritized patients: “I don’t know if I ever had the conversation about how to address it rather than just information about screening intervals and when it is appropriate. Never ‘How do you talk to a transgender person about hey, we still need to do cervical cancer screening’. I’m not sure I’ve had any good training on that.” A White, heterosexual, cisgender woman NP at an urban hospital-affiliated clinic similarly echoed: “And yeah, I know we talked about transgender populations briefly — I don’t really remember how much or what — I’ve never cared for a transgender person, so I feel like that again, hasn’t been reinforced. But it’s unfortunate because I actually feel very nervous about caring for this population, because I feel like their healthcare hasn’t been prioritized in education.”

3.1.3. There are exceptions, and some providers identify effective training opportunities that inform their sexual health communication.

A few providers, however, noted that their prior professional and continuing education training in health disparities, which they intentionally sought out, helped enhance their comfort engaging with minoritized patients in the context of sexual and reproductive healthcare. These additional opportunities included public health education (e.g. MPH degree), independent research, and minority health focused training programs in the community. For example, a White, lesbian, cisgender woman NP at a suburban private practice stated regarding her dissertation focus: “I think because of the work that I did in my dissertation and the work that I have done in LGB health, I think that I am very cognizant of the fact that African-American people are less likely to get Pap smears; are less likely to be treated; are less likely to be covered by insurance.” A White, heterosexual, cisgender woman physician at an urban hospital described intentionally cultivating learning opportunities in transgender and non-binary health: “And then recently, myself and some of the OB/GYN residents […] developed a curriculum to teach in the OB/GYN residency and teach the medical students about how to take care of transgender patients, how to provide competent and welcoming care to transgender patients. And so, because there was nothing formal in any curriculum, we wrote a curriculum for education.”

Public health training beyond medical education also provided additional knowledge on health disparities. An Asian, heterosexual, cisgender woman resident physician at an urban hospital with MPH training referred to her public health training as informative and supplemental to her formal medical training on racial/ethnic disparities. She compared the focus on health equity between her MPH and medical training: “I have an MPH that I did prior to med school so, that was a much stronger component of that training. But in terms of my medical training, I don’t think we’ve had more than a couple of lectures about that topic. [...] So, my concentration was sociomedical sciences […] a lot of what we did was this medical anthropology type of thing where […] we spent a lot of time discussing and talking about how socioeconomic factors impact health so, that was very much something that was on my mind as I went into med school.” A White, heterosexual, cisgender woman physician at an urban hospital who also had an MPH described: “I did a master’s in public health and a very large amount of that was focused on not only just disparities but also policymaking and how policies don’t often mirror reality or even evidence.” She continued about her prior training experiences: “There’s the Adolescent Reproductive Sexual Health Education Project and they have all these online modules you can do. I’ve done a very large amount of their curriculum; Advocates for Youth has a lot of training curriculum, I’ve done that. I’ve attended training with GLASS, which is an LGBTQ youth center in Boston.”

Other providers who had not specifically sought out additional training in racial/ethnic or SGM care described receiving some moderate instruction. Overall, it is important to note that helpful training opportunities in transgender and non-binary care often seemed to narrowly focus on communicating regarding gender-affirming care services, and broad instruction on gender identity and pronouns. A White, heterosexual, cisgender man PA at an urban clinic stated: “I remember several lectures when it came to transgender medicine and helping folks through different transitions. I definitely remember endocrine; we had lectures. I know our psych team definitely talked about the mental health side of things.” A White, heterosexual, cisgender woman PA at an urban community health center described: “We had […] about five hours of training as an entire clinic on gender identity, and gender expression, and using the correct pronouns, and identifying people correctly.” There was, however, more limited focus on other aspects of transgender and non-binary sexual health communication outside of gender-affirming care and broad gender identity issues. A Black, heterosexual, cisgender woman PA at an urban community health center said: “We went over procedures in the surgery between a transgender surgery a little bit, but not in-depth. Then, through work I think we’ve talked more about how to have conversations with that population and not necessarily specific health aspects.” She continued about prior training: “The conversation has been around pronouns or how the person wants to be referred to. I know the clinic shut down for one morning and we all went to this training to discuss it and talk about that. That’s pretty much it.”

In some trainings on racial/ethnic disparities, some providers described being introduced to the role that race has historically played in medicine: “We have been talking a lot about race-based medicine recently, why it exists, how we got to this point, is it helpful, it is harmful. Understanding that all of these medicines that we have tested and said that are safe, we have really only tested in a White male population; we have not actually tested in females and Black communities; we have not tested in other communities,” said a White, heterosexual, cisgender man PA at an urban clinic. Training opportunities in educational settings have also sometimes focused on implicit bias recognition. A White, queer, cisgender woman resident physician at an urban clinic stated: “We had some training in medical school on thinking about bias and unconscious bias and especially in the transition between the preclinical years where you’re doing a lot of studying in textbooks, etc., to the clinical years where you start working in the hospital.”

3.2. Theme 2. Relying on their lived experiences can be a barrier or facilitator to sexual health communication among providers, depending on their own positionality.

3.2.1. Providers with no shared lived experiences with minoritized patients identified limitations to equitable sexual health communication.

A notable number of providers recognized limitations in their ability to assess minoritized patients’ needs based on their lack of lived experiences. Some providers who did not hold minoritized identities frequently commented on their limitations in understanding the perspectives of minoritized patients, despite some prior formal training experiences. For example, one White, heterosexual, cisgender man PA at an urban clinic noted: “I understand that I still have probably a very, very long way to go and the work will never be done. […] I have had some discussions and learnings, but it still feels very far away.” A White, heterosexual, cisgender woman PA at an urban clinic stated: “But I think with a woman having sex with men, I’m more willing to ask questions and say things because that’s my sexual orientation […] I’m trying to think of what questions I would ask but I would feel awkward maybe if a woman that has sex with women is uncomfortable, and then I don’t know exactly what to say.”

3.2.2. Providers identified gaps and areas for improvement in their sexual health communication.

Some providers expressed an overall increased awareness of LGBTQ+ issues broadly in comparison to racial/ethnic disparities issues. Indeed, providers who did not possess a minoritized racial/ethnic identity sometimes expressed comparatively less understanding when discussing racial/ethnic disparities and strategies to redress them, while being more likely to express knowledge toward LGBTQ+-specific information, training, and resources. A White, queer, cisgender woman NP at an urban hospital contrasted provider attitudes toward racial/ethnic and LGBTQ+ minority health issues. She described that White providers may experience discomfort when discussing racial/ethnic minority issues: “I think truthfully it is easier for White people to talk about LGBTQ health than it is to talk about race. I really think it is still quite hard for us to … I mean there is a reason why we have this [LGBTQ+ Pride] sticker on our badge and not a Black Lives Matter sticker on our badge. We have a long way to go.” Ultimately, providers frequently expressed knowledge gaps in areas where they lacked personal lived experiences. A White, heterosexual, cisgender woman NP at an urban hospital-affiliated clinic identified gaps in understanding racial/ethnic minority health issues: “I would like to know more about specifically women’s health problems racial or ethnic minorities are more likely to experience […] yeah, I think that that just hasn’t come up for me too much.” A White, heterosexual, cisgender woman physician at an urban clinic described areas of improvement in transgender and non-binary health: “I think the area that I probably feel less comfortable in that I’d love to be able to watch somebody do the conversation with the patient is how do you approach it [cervical cancer prevention] with transgender patients.”

3.2.3. Some providers hope to establish allyship with minoritized patients despite their lack of shared social identities.

A White, queer, cisgender woman resident physician at an urban clinic specifically identified her identity as White as an important self-reflection opportunity to examine her own positionality when communicating with minoritized patients: “But I can have that conversation in certain situations, and particularly as a White provider, to say I want to make sure that you feel really safe in this hospital. I know that our community is talking about how unsafe women of color feel in a hospital. I want to make sure that you feel safe.” A White, queer, cisgender woman NP at an urban hospital described: “If I am a White person and I am talking to somebody who is White and needs a Pap smear that is going to be a much different conversation than me being a White person and in a position of power over a person of color coming to me for a Pap or a sensitive exam. I think that it is common for us as White people and White clinicians to not think about race because that is just how our culture is and that is white supremacy in medicine. I do think about race when I have a person in front of me who is not White. I try to as best I can figure out how I can be an ally; how do I amplify their voice; how do I not oppress somebody because I am in a position of power. The second I walk through the door I am in a position of power over that person.”

3.2.4. Providers with minoritized social identities draw on their lived experiences to provide equitable sexual health communication.

In contrast, providers who shared minoritized identities with patients described drawing from lived experiences to strengthen sexual health communication. A few providers who mentioned their own sexual minority identity appeared to describe it as important to their ability to understand and address sexual minority patient expectations in clinical decision-making. For example, a White, queer, cisgender woman resident physician at an urban clinic stated: “[…] when I was talking earlier about wanting to make sure that queer women really understand that women who have other partners who are women understand that this is something that they are at risk for. That is something that I feel really confident counseling on because I identify as a queer woman.” Another White, queer, cisgender woman NP at an urban hospital stated: “But I also had to do work in obstetrics which was very interesting and I liked it but it was a super heteronormative more rural practice; nothing about it said LGBTQ. […] for me as a queer person, nothing about walking in there was — ‘Oh this is going to be super welcoming if I ever need to come here for a Pap Smear’, nothing.”

An additional White, lesbian, cisgender woman NP at a suburban private practice specifically drew from her own health experiences: “Because I know for a lot of lesbian women for instance, I am a lesbian so the chance of me having HPV is lower because I am in a committed relationship with my wife. But I have had sex with a male in the past so therefore there is still a chance for me to have HPV.” In terms of racial/ethnic identity, a Black, heterosexual, cisgender woman PA at an urban community health center described how her lived experiences presented the ability to address gaps in patient education in communication: “Since I’m fluent in Haitian-Creole [...] There’s a few words where I was like, now, how would I say this? How would I say that word in Creole? There’s still not even a great word for Pap smear in Creole. Sometimes, it’s more about describing something than actually having a word to translate it.”

3.3. Theme 3. Applying population-level health disparities data can strengthen or hinder effective sexual health communication.

3.3.1. Providers use population-level health disparities data to inform their sexual health communication with minoritized patients.

Some providers described population-level data on health disparities as useful to informing sexual health communication practices with minoritized patients, to the extent that these data helped point to the structural and social factors that perpetuate disparities. Providers described using data to inform their approaches to sexual risk assessment with individual minoritized patients when they could contextualize this data within the broader social context. One White, queer, cisgender woman physician at an urban hospital described: “I would say that specifically, Black women — and Black and brown women […] — are higher-risk for malignant transformation due to structural injustices within the healthcare system that limits their access to preventative resources and also creates a great deal of provider bias against offering those resources early on to those communities.” She continued discussing population-level trends pertaining to sexual orientation: “So, if you have straight people who are still engaging in clinical higher-risk behaviors because they’re probably more likely to have penile/vaginal intercourse […] they’re more likely to be accepted in the healthcare systems and thus more likely to get screened or to be offered the vaccine as a function of both of those. […] I have numerous patients of mine who have never been offered the vaccine because they’ve identified as queer or were told, prior to me, that they didn’t need the vaccine because they identified as lesbian or never been sexually active before, which just makes my skin crawl in thinking about how this misinformation has gotten out there.”

Another White, heterosexual, cisgender woman physician at an urban clinic described: “My understanding […] is that Black women either have more cervical cancer or have more cervical cancer deaths. But I had always in my head thought that that was due to healthcare disparities later in the pipeline, not that they were more likely to get HPV. But just they were less likely to have routine Pap smears or come in for care and get the colpo[scopy] done.” A White, queer, cisgender woman physician at an urban community health center described how she integrates knowledge of population-level disparities when addressing sexual health risk among multiply-minoritized populations, including transgender women of color: “So I do kind of use population medicine, and then apply it to the individual. And if that makes sense, when I look at the risk categories. I’m not saying that the risk factor is the fact that you’re Black, but there are multiple factors that lead to, unfortunately, trans women of color having higher risks of HIV. Again, it’s not because you’re Black. It’s not because you’re trans. There are lots of systems in place, and I don’t want you to be one of those statistics.” Providers also sometimes emphasized that understanding patients’ social histories, and the way that they connect to broader population-level disparities, is important to assessing patients’ sexual risk. A White, queer, cisgender woman physician at an urban community center described: “And then lowest risk [for HPV or cervical cancer] is probably White heterosexual folks, because, again, if you’re queer, if you’re bi, you might not be coming to the doctor. You might feel judged. And then just based on insurance, and who has access to care, and better jobs, etc., disproportionately benefit in the White community. And so, I suspect that it’s lower rates in White women, White cis heterosexual women have access to all those things.”

3.3.2. Some providers use population-level health disparities data to address medical racism and center minoritized patients’ autonomy.

Providers may also use population-level health disparities data to address historical medical abuse among racially/ethnically minoritized communities, and, in the process, help to center patient autonomy in social context. To do so, providers described shaping their sexual health communication so that it is intentionally accommodating and minimally coercive. A White, queer, cisgender woman NP at an urban hospital commented on her desire to not appear coercive in her counseling: “I am much more deliberate about explaining what a Pap smear is for any person of color because there has been a very dark history of coercion when it comes to gynecologic health for people who are of color and Black people. Instead of saying you need a Pap, and that is it, I am going to spend a lot more time explaining to a person that it is a pelvic exam; it is a screening. I will tell them exactly how it is done, what it is for, where the cells are going.”

A White, queer, cisgender woman physician at an urban hospital stated: “The one population where I tend to see more of a difficulty are my patients who are recently immigrated to the US. [...] I have to be very careful about my words because I don’t want anything to come across as me saying, ‘You have to get this vaccine.’ Like, autonomy is everything.” Thus, for some providers, population-level background knowledge is applied to minimize risk of medical coercion and paternalism when counseling minoritized patients. A White, queer, cisgender woman resident physician at an urban clinic stated: “[…] I’m very aware of the statistics that make it more difficult to access cervical cancer screening [for women of color]. So, that influences my counseling in terms of saying I care about you; this is something that’s really important for your health. I want to make sure we do this in a way that feels comfortable for you or that we address whatever you’re worried about.”

3.3.3. Population-level health disparities data can be reductionistic, and some providers try to avoid oversimplification.

In contrast, some providers described population-level disparities data as reductionist and even drawing from stereotypical depictions of minoritized groups. In the process, such reductionist depictions may not address the broader social determinants that shape patients’ health. Providers related their experiences being exposed to such reductionist depictions to subsequently feeling limited in communicating about sexual health. For example, underscoring racial bias in her training, a White, heterosexual, cisgender woman physician at an urban clinic noted: “They used a very outdated textbook; it was very uncomfortable. There was a lot of reading about, like, Latino patients want you to be simpatico.”

Some providers also described that some population-level disparities data does not explicitly recognize the role of broader structural and social determinants, and may not delve into specific barriers to care or risk factors. A multiracial, heterosexual, cisgender woman resident physician at a suburban clinic described: “[…] a lot of really complex epidemiological studies look at gender, sexual preference, race, socioeconomic status and the whole gamut and how that affects your risk for HPV or how it affects your risk for other things. And I’m sure the literature reflects that minoritized social groups are at higher risk for getting HPV […] so, I actually don’t know if that’s true or not, but I think if anything, it’s probably because there’s silos of medical care and difficulties in getting these populations into your office to begin with.”

Some providers additionally described that while data are informative, they should merely guide clinical decision-making, leaving room for individualized counseling. A White, heterosexual, cisgender woman PA at an urban community health center described: “As medical providers we like the statistics and the facts […] Certainly don’t want to use statistics about who gets cervical cancer more to decide who I am going to offer cervical cancer screening to. But thinking about, okay, how do I use those statistics to guide the things that I say, how do I counsel an African-American woman about actually, your risk is twice as high…” An Asian, heterosexual, cisgender woman resident physician at an urban hospital described: “I think with an individual patient encounter, it doesn’t factor so much. I mean, I think the data shows that Black and Hispanic women are more likely to have cervical cancer, but I think that’s more a question of access and not necessarily related to individual behavior. [...] So, I think sometimes this data that’s kind of by population level can be useful but can also maybe not apply in the same way when you’re having individual conversations.”

A White, queer, cisgender woman NP at an urban hospital described the importance, when communicating sexual health information, of drawing together different population-level data to inform unique positionalities of each patient: “I think the main points I try to hit home are I tell them in populations of women having sex with women are traditionally under-screened. Then if I have a person of color, Black person in front of me who is a woman who is having sex with a woman, I say you are likely to be under-screened even more. If I have a trans woman of color or Black trans woman in front of me, I am going to say — these are the things you are at more risk of and how can I help.” A multiracial, heterosexual, cisgender woman resident at a suburban clinic described the importance of individualized counseling that extends beyond population-level data: “So, I think it depends on the patient’s particular history; aside from the patient’s medical history and their willingness to do it, I don’t take anything else into consideration.” She continued describing that she does not translate population statistics directly to patient care when counseling on sexual health: “I’m not quoting the literature here — but I don’t necessarily think I would be like, ‘Oh, you are Hispanic, so I will make sure you get the HPV vaccine’, or ‘Oh, you’re White and you don’t have sex with anyone, so you don’t need…’”

4. DISCUSSION

The present study explored three key areas relevant to promoting equitable sexual health communication that addresses the needs of minoritized racial/ethnic, sexual orientation, and gender identity AFAB patients. We explored how providers’ prior training (or lack thereof), lived experiences and social positionalities, and application of population-level data influenced their sexual health communication. Prior research has focused on patient perspectives, rather than the role of providers in supporting or hindering patient needs through patient-provider communication. Thus, our study adds to the existing literature by examining how providers’ perspectives regarding their attitudes, knowledge, and skills in sexual health communication influence the clinical encounter. Our findings point to strategies, including applying population-level disparities data in context, and resources, such as minoritized providers’ own lived experiences, on which providers can rely to meaningfully promote equity in their sexual health communication. Our study also identified several challenges to doing so, however, including a lack of robust training opportunities. Additionally, our study illustrates some overarching commonalities in providers’ attitudes, knowledge, and skills related to sexual health communication and care across minoritized groups. Indeed, when engaging with minoritized racial/ethnic, sexual orientation, and gender identity AFAB patients, providers must frequently confront and navigate reductionist and stereotypical depictions about these groups based on their prior training, and may struggle to identify with patients who hold different identities from themselves.

Our study findings should be interpreted in the context of several limitations. Firstly, participants were primarily White, cisgender, heterosexual women who were NPs, non-resident physicians, and PAs practicing in urban clinics, community health centers, and hospitals. Future studies including providers with more diverse professional (e.g., healthcare discipline, practice setting) and demographic (e.g., gender identity, race/ethnicity, and sexual orientation) backgrounds are needed. Our interviews were conducted in Massachusetts and Rhode Island, and providers in other geographic areas may have different perspectives and experiences. Future studies in other areas with different healthcare and policy landscapes are needed. Additionally, our findings cannot be triangulated with other data sources to obtain a holistic understanding of the issues of interest; thus, we recommend further multi- and mixed methods studies that allow for data triangulation. Lastly, our interview questions focused on provider decision-making for racial/ethnic and SGM groups separately, and did not incorporate questions specifically referencing multiply-minoritized patients. Thus, providers seldom readily and deliberately spoke about patients with multiple minoritized identities, perhaps indicating that when not specifically probed on this matter, this topic was not at the forefront of providers’ conceptualizations of care for minoritized patients. To elicit more robust discussion on this topic, questions pertaining to intersectionality should thus be incorporated into future research that specifically addresses how providers conceptualize care for patients whose lives and care are impacted by multiple intersecting social inequities.

Despite these limitations, our study has several notable implications. Our study findings indicated that providers should be comprehensively trained to affirm sexual minority health issues, including the experiences of SMW, who have frequently reported discomfort when providers do not demonstrate an affirming attitude (McNair et al., 2015; Rhoten et al., 2022). As conceptualized within the framework of person-centered care (Morgan & Yoder, 2012), healthcare professional education should also comprehensively integrate, through a gender-diverse lens, training on topics such as gender-affirming care, transgender health disparities, culturally competent terminologies and pronoun usage, contraception, and more (Pulice-Farrow et al., 2021). Additionally, in our study, providers seldom discussed intersectional identities, and should therefore be trained on the experiences of multiply-minoritized populations, who experience magnified adverse health outcomes, a recommendation that would align with the tenets of intersectionality (Okoro et al., 2022; Tan et al., 2016). Intersectional approaches to provider training could incorporate education on the nature of power dynamics in clinical care and how they disproportionately impact multiply-minoritized patients, discuss the role of medical mistrust experienced by these minoritized patients, and incorporate more diverse and positive portrayals of multiply-minoritized people within educational and media settings in response to prevalent biased and stigmatizing stereotypes (Rosenthal & Lobel, 2020; Samra & Hankivsky, 2021; Tan et al., 2016).

Our study findings additionally indicated that providers’ clinical training and continuing education on racial/ethnic health disparities largely focused on broad population trends, rather than structural inequities. We believe it is necessary to ground these implications within the broader history of sexual and reproductive health. Minoritized racial/ethnic identity, particularly Black, AFAB individuals have reported deep medical mistrust as a result of experiences including sexual commodification, forced sterilization, interpersonal racism, and measures of population control intended to place bodies under state control and surveillance (Black et al., 2021; Wilson, 2021). Thus, within this context, healthcare providers must be adequately trained in anti-racist approaches to begin interrupting normative cultures of white supremacy (Lee Bishop et al., 2022; Mitchell & Williamson, 2022). Training should also emphasize critical reflection of positionality, focusing on discussions that extend beyond cultural competence or humility to emphasize critical praxis (Altman et al., 2021; Muldoon, 2022). Furthermore, there is a need for person-centered communication that incorporates shared decision-making, in which patients’ sexual health preferences, priorities, and values are prioritized (Bi et al., 2019; DeMeester et al., 2016).

Moreover, minoritized AFAB patients have frequently described a preference for healthcare providers who share their lived experiences (Agénor et al., 2015; Thompson et al., 2022; Townes et al., 2022). Patients whose identities are concordant with those of their providers have reported better health communication outcomes and higher levels of trust and satisfaction (Greenwood et al., 2020; Shen et al., 2018). Overall, there is a critical need for training and delivery institutions to recruit, train, and support diverse providers who reflect the lived experiences of minoritized patients at diverse intersections, including LGBTQ+ people of color (Campbell et al., 2018). However, it is also important to consider the complexity of power dynamics in patient-provider encounters, which can introduce nuances that complicate a simplistic recommendation to recruit providers of the same lived experiences as minoritized patients. For example, prior research has indicated that ethnic concordance between providers and patients with minoritized social positions can actually instigate additional power imbalances that can negatively impact the patient experience in clinical encounters, highlighting the impact of the broader professional context in which providers operate (Lo & Bahar, 2013). Thus, recommendations focused on diversifying the provider workforce must be implemented with attention to broader structural and organizational change, such as prioritizing equitable organizational policies within the workforce setting (DeMeester et al., 2016).

Ultimately, the potential limitations of competence-based training, individual-level communication recommendations, and provider-level changes must be noted, particularly within the framework of structural competency (Calabrese et al., 2022). Indeed, the structural competency framework elucidates the higher-level influence of structures, including socio-political forces in broader society, that shape patients’ experiences of care (Metzl & Hansen, 2014). Thus, in accordance with Metzl & Hansen’s (2014) structural competency framework, establishing an inclusive organizational context is essential to advancing equitable sexual health communication and care, as is implementing reform at the structural level, including institutional policies and practices that advance equity such as those focused on inclusive language and mission statements in the workplace (DeMeester et al., 2016; Scholl et al., 2018). Within such a theoretical framework, healthcare organizations should intentionally create educational and clinical practice environments that advance equity, including by implementing equitable organizational procedures, fostering bidirectional relationships with minoritized communities, and providing resources to realize equitable policies, processes, and norms (DeMeester et al., 2016; Scholl et al., 2018). For example, healthcare organizations should implement policies that ensure inclusive language in mission statements and clinical materials, leadership affirmation of values around justice and equity, mechanisms for feedback from community members, institutional programs serving minoritized staff (e.g., mentoring programs), and quality improvement measures that address healthcare inequities (DeMeester et al., 2016; Piggott & Cariaga-Lo, 2019). To promote accountability, there should also be transparent dissemination regarding progress and benchmarks for institutional diversity, equity, and justice (Piggott & Cariaga-Lo, 2019).

5. CONCLUSION

We found that most providers in our study lacked robust training in racial/ethnic health equity and LGBTQ+ health. These gaps in training resulted in uncertainty toward providing equitable sexual health communication and care to patients with minoritized racial/ethnic, sexual orientation, and gender identities, especially among providers who did not share these minoritized social positions. In contrast, providers with minoritized racial/ethnic and sexual orientation identities described being able to leverage their lived experiences to positively inform their sexual health communication, and in turn, promote equitable communication and care. Additionally, many providers reported relying, to a large extent, on population-level health disparities data to inform their communication and care with minoritized patients. However, several providers warned that, while this information can be useful to the extent that it points to addressing the structural and social factors that shape inequities, using population-level disparities data to guide sexual health communication and care with individual minoritized patients can undermine engagement in person-centered practices that promote patient autonomy, health, and well-being. To ensure that minoritized patients receive equitable, anti-racist, and LGBTQ+-competent sexual health communication and care, patients’ needs must be understood in historical and social context. Thus, provider training should emphasize the influence of historical and contemporary racism, sexism, heterosexism, cisgenderism, and their intersections on sexual health inequities and consider pathways to redress their societal harms in clinical practice. Furthermore, healthcare institutions should actively train, recruit, and support providers with minoritized racial/ethnic, sexual orientation, and gender identities and foster equitable organizational structures, practices, and norms that advance the health and well-being of both patients and providers from minoritized communities.

• Providers may have limited training in racial/ethnic and LGBTQ+ health disparities

• Poor training can weaken sexual health communication with minoritized patients

• Lived experiences are key to sexual health communication with these patient groups

• Population-level disparities data can be a barrier or facilitator based on context

• Robust anti-racist and LGBTQ+ training is needed among sexual healthcare providers

Data Availability Statement

Our informed consent form limits the use of the data to this present study; as such, the data is not available for use by other researchers. Upon reasonable request, the in-depth interview guides used in this study may be made available.