Transgender (trans) people experience high rates of mental health issues including depression and... more Transgender (trans) people experience high rates of mental health issues including depression and suicidality. Improving access to transition-related medicine such as hormones and surgeries is suggested as an important mechanism to address these mental health issues. Yet clinicians experience challenges assessing and referring trans people for transition-related medicine. Standardized assessment protocols have been therefore recommended to optimize care. Although standardized protocols are purported to expand access to hormones and surgeries for trans people, it is unclear whether these tools achieve this goal. We therefore conducted an institutional ethnography to explicate how standardized readiness assessments coordinate access to hormones and surgeries in Canada. We analyzed key texts, talked with trans people, clinicians, clinician-educators, and administrators (total n=22), and observed clinician-education workshops. In the context of determining transition readiness, standardized protocols direct clinicians to explore alternative diagnoses and assess the degree to which any complex mental health condition is “managed” prior to initiating hormones or surgeries. In response, we found that trans patients downplay or withhold mental health concerns from clinicians, or otherwise do additional work (e.g., take up unwanted psychiatric interventions) to convince providers they are “mentally ready” to transition. This phenomenon is paradoxical in that transition-related medicine is recommended to mitigate trans people’s psychosocial distress, but when patients reveal symptoms of distress they encounter significant barriers to treatment. We conclude that the logic underpinning pre-transition “mental readiness” assessments discredits the claim that standardized protocols optimize access to hormones and surgeries.
Evidenced by leading journals in academic medicine, health professions education has taken up the... more Evidenced by leading journals in academic medicine, health professions education has taken up the call to advance equitable healthcare. One pressing area where gaps and inequities are apparent is transgender (trans) people’s access to gender-affirming medicine such as hormones and surgeries. Reasons for the dire state of care include education gaps. While specific content knowledge has been identified as lacking in medical school curricula, less research has focused on the complex social practices required of clinicians and educators working in gender-affirming medicine, and how these skills are learned through practice. In order to inform health professions education in this key area of need, we conducted a study to better understand the social practices, and the learning that occurs therein, of gender-affirming medicine. We identified the work processes of 22 clinicians, clinician-educators, trans patients, and clinical care administrators with attention to how policies and protocols influenced practice, learning, and teaching. The results of our study elucidate: (1) practicing of gender-affirming medicine is strictly dictated by standardized assessment protocols, which serve as a form of curriculum; and (2) how health professionals learn and teach health advocacy as a form of resistance to protocols identified as creating inequities. These findings suggest an opportunity to view protocols – and their inherent limitations – more deliberately as teaching and learning tools, specifically for learning advocacy.
Over the past decade, evidence has accumulated to suggest that bisexual people experience higher ... more Over the past decade, evidence has accumulated to suggest that bisexual people experience higher rates of poor mental health outcomes compared to both heterosexual and gay/lesbian individuals. However, no previous meta-analyses have been conducted to establish the magnitude of these disparities. To address this research gap, we conducted a systematic review and meta-analysis of studies that reported bisexual-specific data on standardized measures of depression or anxiety. Of the 1,074 full-text articles reviewed, 1,023 were ineligible, predominantly because they did not report separate data for bisexual people (n = 562 studies). Ultimately, 52 eligible studies could be pooled in the analysis. Results indicate that across both outcomes, there is a consistent pattern of lowest rates of depression and anxiety among heterosexual people, while bisexual people exhibit higher or equivalent rates in comparison to lesbian/ gay people. On the basis of empirical and theoretical literature, we propose three interrelated contributors to these disparities: experiences of sexual orientation-based discrimination, bisexual invisibility/erasure, and lack of bisexual-affirmative support. Implications for interventions to improve the health and well-being of bisexual people are proposed.
Lesbian and bisexual women who were pregnant (N=16), biological (N=18) or non-biological (N=15) p... more Lesbian and bisexual women who were pregnant (N=16), biological (N=18) or non-biological (N=15) parents completed the Edinburgh Postnatal Depression Scale (EPDS), and scores were compared to a previously published heterosexual sample. Lesbian and bisexual biological mothers had significantly higher EPDS scores than the previously published sample of heterosexual women. Results suggest that perinatal depression is not less common and may be more common among lesbian and bisexual women relative to heterosexual women. Additional, longitudinal studies are needed.
Bisexuals are at greater risk for poor mental health compared to heterosexual, gay, and lesbian p... more Bisexuals are at greater risk for poor mental health compared to heterosexual, gay, and lesbian people. This increased risk has been attributed to biphobia yet the relationship between biphobia and mental health has been understudied. Data were collected from an Ontario-wide survey of bisexuals, broadly defined, using respondent-driven sampling (N=405) and minority stress theory was applied to examine the relationship between biphobia (from the straight community and gay/lesbian community separately) and anxiety using structural equation modelling. In contrast to our hypothesis, biphobia had little impact on anxiety. Results suggest that we need to enhance our capacity to measure discrimination.
Research suggests an elevated level of posttraumatic stress disorder (PTSD) among bisexuals. The ... more Research suggests an elevated level of posttraumatic stress disorder (PTSD) among bisexuals. The PTSD Checklist – Civilian version (PCL-C) is a self-report measure used to assess PTSD symptoms in non-military persons, closely following DSM-IV criteria. In a study of 405 bisexuals in Ontario, Canada, we evaluated the PCL-C using confirmatory factor analysis and found it performed poorly. We caution researchers to be aware of the PCL-C’s limitations. We concur that the three symptom clusters may not be the best way to evaluate the presence of PTSD, an issue that may be alleviated with PCL-C revisions to align with DSM-V criteria.
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstétrique et gynécologie du Canada : JOGC., 2006
Increasing numbers of lesbian and bisexual women are choosing to have children. This qualitative ... more Increasing numbers of lesbian and bisexual women are choosing to have children. This qualitative study investigated the degree to which a sample of Canadian lesbian and bisexual women were satisfied with the health and social services that they received during the process of trying to conceive, during pregnancy, and during the early postpartum weeks and months. Three focus groups were conducted: (1) women who were themselves, or whose partners were, in the process of trying to conceive (n = 6); (2) biological parents of young children (n = 7); and (3) women who were non-biological parents of young children or whose partners were currently pregnant (n = 10). Participants were asked to discuss their positive and negative experiences with health and social services during their efforts to conceive and through the perinatal period. Participants were very satisfied with the care they received from midwives, doulas, and public health nurses. Services directed specifically to lesbian, gay, and bisexual parents were also perceived to be important sources of information and support. Many participants perceived fertility services to be unsupportive or unable to address their different health care needs. Participants expressed satisfaction with pregnancy-related services provided by non-physicians and dissatisfaction with services provided by physicians and fertility clinics. There is a strong desire for fertility services specific to lesbian and bisexual women, but even minor changes to existing services could improve the satisfaction of lesbian and bisexual patients.
To date, there is little evidence to inform social work practice with lesbian and bisexual women ... more To date, there is little evidence to inform social work practice with lesbian and bisexual women who are trying to conceive (TTC). The authors report a preliminary examination of the mental health experiences of lesbian and bisexual women who are TTC, through a comparison with lesbian and bisexual women in the postpartum period (PP). Thirty-three lesbian and bisexual women (TTC, n = 15; PP, n = 18) completed standardized questionnaires assessing symptoms of depression and anxiety as well as relationship satisfaction and perceived social support. Qualitative interviews were also conducted to further investigate the experience of TTC. No significant differences were found between groups on any of the dependent variables. Analysis of qualitative data highlighted the challenges for lesbian and bisexual women who are TTC, particularly in terms of difficulty conceiving, lack of support during the conception process, and heterosexism in the fertility system. Women perceived these challenges to conception as having emotional consequences. The findings from this study begin to elucidate the unique context of TTC for lesbian and bisexual women, and they highlight the importance of culturally competent social work practice with this population.
Lesbian, gay, and bisexual women undertake parenting in a social context that may be associated w... more Lesbian, gay, and bisexual women undertake parenting in a social context that may be associated with unique risk factors for perinatal depression. This cross-sectional study aimed to describe the mental health services used by women in the perinatal period and to identify potential correlates of mental health service use. Sixty-four women who were currently trying to conceive, pregnant, or the parent of a child less than one year of age were included. One-third of women reported some mental health service use within the past year; 30.6% of women reported a perceived unmet need for mental health services in the past year, with 40% of these women citing financial barriers as the reason for their unmet need. Women who were trying to get pregnant or who were less "out" were most likely to have had recent mental health service use. Women who had conceived by having sex with a man or who reported more than three episodes of discrimination were most likely to report unmet needs for mental health services. Providers may benefit from additional knowledge about the LBG social context that is relevant to perinatal health, and from identifying a strong referral network of skilled and affordable counsellors.
Feminisms in Social Work Research Promise and possibilities for justice-based knowledge .
In this chapter, we examine our engagement with critical feminism in research within the context ... more In this chapter, we examine our engagement with critical feminism in research within the context of an ongoing critical, collaborative, and interdisciplinary research project. We speak from our respective social identities and locations to explore feminist research issues including epistemology, collaborative methodology and representation, ethics, collaborative knowledge production, and communication with relevant audiences. Throughout the chapter we contextualize our reflections in current debates within both feminist and service user research literature as informed by the disability rights and consumer/survivor (C/S) movements.
Objective: The lesbian patient population is underserved. Almost no research has examined the kno... more Objective: The lesbian patient population is underserved. Almost no research has examined the knowledge and attitudes of obstetrician-gynecologists toward lesbian health. Our study sought to address this research gap. Methods: All 910 obstetrician-gynecologists licensed in Ontario, Canada, were mailed a true-false survey about lesbian health issues, the Homosexuality Attitudes Scale (HAS), and a demographic survey. Results: Of the 910 surveys, 271 were returned. The mean HAS score was 87.6 (standard deviation [SD] 11.5), indicating an overall positive attitude. The mean knowledge score was 76.0% (SD 9.5), indicating that respondents had adequate knowledge about lesbian health; 22% described their lesbian health knowledge-base as unaware. Most respondents reported lack of education on lesbian health in residency (81%) or medical school (78%). The majority reported a desire for formal education pertaining to lesbian health. There was no correlation between HAS and knowledge scores. Conclusions: Although our results indicate overall adequate knowledge about lesbian health issues, important knowledge gaps were identified. Medical school and residency training curricula should include formal education about lesbian health issues, particularly because most obstetrician-gynecologists report a desire to receive this information.
Objective: To determine what recommendations lesbian, gay, bisexual, trans, and queer (LGBTQ) peo... more Objective: To determine what recommendations lesbian, gay, bisexual, trans, and queer (LGBTQ) people have for provision of assisted human reproduction (AHR) services to their communities.
Methods: Using a semi-structured guide, we interviewed a purposeful sample of 66 LGBTQ-identified individuals from across the province of Ontario who had used or had considered using AHR services since 2007.
Results: Participants were predominately cisgender (non-trans), white, same-sex partnered, urban women with relatively high levels of education and income. Participants made recommendations for changes to the following aspects of AHR service provision: (1) access to LGBTQ-relevant information, (2) adoption of patient-centred practices by AHR service providers, (3) training and education of service providers regarding LGBTQ issues and needs, (4) increased visibility of LGBTQ people in clinic environments, and (5) attention to service gaps of particular concern to LGBTQ people.
Conclusion: Many of the recommendations made by study participants show how patient-centred models may address inequities in service delivery for LGBTQ people and for other patients who may have particular AHR service needs. Our results suggest that service providers need education to enact these patient-centred practices and to deliver equitable care to LGBTQ patients.
Objective: To determine the effectiveness of interactive theatre as a knowledge translation and e... more Objective: To determine the effectiveness of interactive theatre as a knowledge translation and exchange (KTE) method to educate assisted human reproduction (AHR) service providers about lesbian, gay, bisexual, trans and queer (LGBTQ) patients.
Design: We transformed data from the ‘Creating Our Families’ study, a qualitative, community-based study of LGBTQ peoples’ experiences accessing AHR services, into a script for an interactive theatre workshop for AHR service providers. Based on forum theatre principles, our workshop included five scenes illustrating LGBTQ people interacting with service providers, followed by audience interventions to these scenes. Before and after the workshop, service providers completed surveys to assess their knowledge and comfort concerning LGBTQ patients, as well as the modality of the interactive theatre workshop as a KTE strategy. Wilcoxon signed-rank tests were used to determine changes in preworkshop and postworkshop knowledge and comfort scores.
Results: Thirty AHR service providers attended the workshop. Twenty-three service providers (76.7%) fully completed the preworkshop and postworkshop evaluation forms. Service providers’ knowledge scores significantly improved after the workshop, while their comfort scores minimally decreased. Most agreed that the interactive workshop was an effective KTE method.
Conclusions: In comparison with traditional forms of KTE, interactive theatre may be particularly effective in engaging service providers and addressing their attitudes towards marginalised patient populations. Although the evaluation results of our interactive workshop were mostly positive, the long-term impact of the workshop is unknown. Long-term evaluations are needed to determine the effectiveness of arts-based KTE efforts. Other considerations for developing effective arts-based KTE strategies include adequate funding, institutional support, attention to power dynamics and thoughtful collaboration with forum theatre experts.
PURPOSE:
Few studies have examined the role of culture in a woman's experience of postpartum moo... more PURPOSE:
Few studies have examined the role of culture in a woman's experience of postpartum mood problems (PPMP). This study explored differences and similarities in experiences of PPMP between first- and second-generation Canadian women.
DESIGN:
In this exploratory qualitative study, we interviewed nine first-generation and eight second-generation women who were clients of the Women's Health Centre at St. Joseph's Health Centre in Toronto, Canada. Using semistructured interviews, we explored how women perceived and experienced PPMP.
FINDINGS:
Four themes reflected cultural issues: PPMP stigma, relationship with parents/in-laws, internalization of society's expectations of motherhood, and identity issues/relationship with self.
DISCUSSION:
The results of this study contribute to a limited literature on possible contributing factors to PPMP and can inform development of resources for delivering culturally appropriate mental health care for women dealing with PPMP.
IMPORTANCE:
Untreated depression during pregnancy has been associated with increased morbidity an... more IMPORTANCE: Untreated depression during pregnancy has been associated with increased morbidity and mortality for both mother and child and, as such, optimal treatment strategies are required for this population. CONTEXT: There are conflicting data regarding potential risks of prenatal antidepressant treatment. OBJECTIVE: To determine whether prenatal antidepressant exposure is associated with risk for selected adverse pregnancy or delivery outcomes. DATA SOURCES MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library were searched from their start dates to June 30, 2010. STUDY SELECTION English-language studies reporting outcomes associated with pharmacologic treatment during pregnancy were included. We reviewed 3074 abstracts, retrieved 735 articles, and included 23 studies in this meta-analysis. DATA EXTRACTION: Study design, antidepressant exposure, adjustment for confounders, and study quality were extracted by 2 independent reviewers. RESULTS: There was no significant association between antidepressant medication exposure and spontaneous abortion (odds ratio [OR], 1.47; 95% CI, 0.99 to 2.17; P = .055). Gestational age and preterm delivery were statistically significantly associated with antidepressant exposure (mean difference [MD] [weeks], -0.45; 95% CI, -0.64 to -0.25; P < .001; and OR, 1.55; 95% CI, 1.38 to 1.74; P < .001, respectively), regardless of whether the comparison group consisted of all unexposed mothers or only depressed mothers without antidepressant exposure. Antidepressant exposure during pregnancy was significantly associated with lower birth weight (MD [grams], -74; 95% CI, -117 to -31; P = .001); when this comparison group was limited to depressed mothers without antidepressant exposure, there was no longer a significant association. Antidepressant exposure was significantly associated with lower Apgar scores at 1 and 5 minutes, regardless of whether the comparison group was all mothers or only those who were depressed during pregnancy but not exposed to antidepressants. CONCLUSIONS AND RELEVANCE: Although statistically significant associations between antidepressant exposure and pregnancy and delivery outcomes were identified, group differences were small and scores in the exposed group were typically within the normal ranges, indicating the importance of considering clinical significance. Treatment decisions must weigh the effect of untreated maternal depression against the potential adverse effects of antidepressant exposure.
OBJECTIVE:
Depression is often not optimally treated during pregnancy, partially because of confl... more OBJECTIVE: Depression is often not optimally treated during pregnancy, partially because of conflicting data regarding antidepressant medication risk. This meta-analysis was conducted to determine whether antenatal antidepressant exposure is associated with congenital malformations and to assess the effect of known methodological limitations. DATA SOURCES: EMBASE, CINAHL, PsycINFO, and MEDLINE were searched from their start dates to June 2010. Keywords of various combinations were used, including, but not limited to depressive/mood disorder, pregnancy, antidepressant drug/agent, congenital malformation, and cardiac malformation. STUDY SELECTION: English language studies reporting congenital malformations associated with antidepressants were included. Of 3,074 abstracts reviewed, 735 studies were retrieved and 27 studies were included. DATA EXTRACTION: Two reviewers working independently assessed article quality. Data on use of any antidepressant, including fluoxetine and paroxetine specifically, were extracted. Outcomes included congenital malformations, major congenital malformations, cardiovascular defects, septal heart defects (ventral septal defects and atrial septal defects), and ventral septal defects only. RESULTS: Nineteen studies were above quality threshold and make up the primary meta-analyses. Pooled relative risks (RRs) were derived by using random-effects methods. Antidepressant exposure was not associated with congenital malformations (RR = 0.93; 95% CI, 0.85-1.02; P = .113) or major malformations (RR = 1.07; 95% CI, 0.99-1.17; P = .095). However, increased risk for cardiovascular malformations (RR = 1.36; 95% CI, 1.08-1.71; P = .008) and septal heart defects (RR = 1.40; 95% CI, 1.10-1.77; P = .005) were found; the RR for ventral septal defects was similar to septal defects, although not significant (RR = 1.54; 95% CI, 0.71-3.33; P = .274). Pooled effects were significant for paroxetine and cardiovascular malformations (RR = 1.43; 95% CI, 1.08-1.88; P = .012). These results are contrasted with those addressing methodological limitations but are typically consistent. CONCLUSIONS: Overall, antidepressants do not appear to be associated with an increased risk of congenital malformations, but statistical significance was found for cardiovascular malformations. Results were robust in several sensitivity analyses. Given that the RRs are marginal, they may be the result of uncontrolled confounders. Although the RRs were statistically significant, none reached clinically significant levels.
Transgender (trans) people experience high rates of mental health issues including depression and... more Transgender (trans) people experience high rates of mental health issues including depression and suicidality. Improving access to transition-related medicine such as hormones and surgeries is suggested as an important mechanism to address these mental health issues. Yet clinicians experience challenges assessing and referring trans people for transition-related medicine. Standardized assessment protocols have been therefore recommended to optimize care. Although standardized protocols are purported to expand access to hormones and surgeries for trans people, it is unclear whether these tools achieve this goal. We therefore conducted an institutional ethnography to explicate how standardized readiness assessments coordinate access to hormones and surgeries in Canada. We analyzed key texts, talked with trans people, clinicians, clinician-educators, and administrators (total n=22), and observed clinician-education workshops. In the context of determining transition readiness, standardized protocols direct clinicians to explore alternative diagnoses and assess the degree to which any complex mental health condition is “managed” prior to initiating hormones or surgeries. In response, we found that trans patients downplay or withhold mental health concerns from clinicians, or otherwise do additional work (e.g., take up unwanted psychiatric interventions) to convince providers they are “mentally ready” to transition. This phenomenon is paradoxical in that transition-related medicine is recommended to mitigate trans people’s psychosocial distress, but when patients reveal symptoms of distress they encounter significant barriers to treatment. We conclude that the logic underpinning pre-transition “mental readiness” assessments discredits the claim that standardized protocols optimize access to hormones and surgeries.
Evidenced by leading journals in academic medicine, health professions education has taken up the... more Evidenced by leading journals in academic medicine, health professions education has taken up the call to advance equitable healthcare. One pressing area where gaps and inequities are apparent is transgender (trans) people’s access to gender-affirming medicine such as hormones and surgeries. Reasons for the dire state of care include education gaps. While specific content knowledge has been identified as lacking in medical school curricula, less research has focused on the complex social practices required of clinicians and educators working in gender-affirming medicine, and how these skills are learned through practice. In order to inform health professions education in this key area of need, we conducted a study to better understand the social practices, and the learning that occurs therein, of gender-affirming medicine. We identified the work processes of 22 clinicians, clinician-educators, trans patients, and clinical care administrators with attention to how policies and protocols influenced practice, learning, and teaching. The results of our study elucidate: (1) practicing of gender-affirming medicine is strictly dictated by standardized assessment protocols, which serve as a form of curriculum; and (2) how health professionals learn and teach health advocacy as a form of resistance to protocols identified as creating inequities. These findings suggest an opportunity to view protocols – and their inherent limitations – more deliberately as teaching and learning tools, specifically for learning advocacy.
Over the past decade, evidence has accumulated to suggest that bisexual people experience higher ... more Over the past decade, evidence has accumulated to suggest that bisexual people experience higher rates of poor mental health outcomes compared to both heterosexual and gay/lesbian individuals. However, no previous meta-analyses have been conducted to establish the magnitude of these disparities. To address this research gap, we conducted a systematic review and meta-analysis of studies that reported bisexual-specific data on standardized measures of depression or anxiety. Of the 1,074 full-text articles reviewed, 1,023 were ineligible, predominantly because they did not report separate data for bisexual people (n = 562 studies). Ultimately, 52 eligible studies could be pooled in the analysis. Results indicate that across both outcomes, there is a consistent pattern of lowest rates of depression and anxiety among heterosexual people, while bisexual people exhibit higher or equivalent rates in comparison to lesbian/ gay people. On the basis of empirical and theoretical literature, we propose three interrelated contributors to these disparities: experiences of sexual orientation-based discrimination, bisexual invisibility/erasure, and lack of bisexual-affirmative support. Implications for interventions to improve the health and well-being of bisexual people are proposed.
Lesbian and bisexual women who were pregnant (N=16), biological (N=18) or non-biological (N=15) p... more Lesbian and bisexual women who were pregnant (N=16), biological (N=18) or non-biological (N=15) parents completed the Edinburgh Postnatal Depression Scale (EPDS), and scores were compared to a previously published heterosexual sample. Lesbian and bisexual biological mothers had significantly higher EPDS scores than the previously published sample of heterosexual women. Results suggest that perinatal depression is not less common and may be more common among lesbian and bisexual women relative to heterosexual women. Additional, longitudinal studies are needed.
Bisexuals are at greater risk for poor mental health compared to heterosexual, gay, and lesbian p... more Bisexuals are at greater risk for poor mental health compared to heterosexual, gay, and lesbian people. This increased risk has been attributed to biphobia yet the relationship between biphobia and mental health has been understudied. Data were collected from an Ontario-wide survey of bisexuals, broadly defined, using respondent-driven sampling (N=405) and minority stress theory was applied to examine the relationship between biphobia (from the straight community and gay/lesbian community separately) and anxiety using structural equation modelling. In contrast to our hypothesis, biphobia had little impact on anxiety. Results suggest that we need to enhance our capacity to measure discrimination.
Research suggests an elevated level of posttraumatic stress disorder (PTSD) among bisexuals. The ... more Research suggests an elevated level of posttraumatic stress disorder (PTSD) among bisexuals. The PTSD Checklist – Civilian version (PCL-C) is a self-report measure used to assess PTSD symptoms in non-military persons, closely following DSM-IV criteria. In a study of 405 bisexuals in Ontario, Canada, we evaluated the PCL-C using confirmatory factor analysis and found it performed poorly. We caution researchers to be aware of the PCL-C’s limitations. We concur that the three symptom clusters may not be the best way to evaluate the presence of PTSD, an issue that may be alleviated with PCL-C revisions to align with DSM-V criteria.
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstétrique et gynécologie du Canada : JOGC., 2006
Increasing numbers of lesbian and bisexual women are choosing to have children. This qualitative ... more Increasing numbers of lesbian and bisexual women are choosing to have children. This qualitative study investigated the degree to which a sample of Canadian lesbian and bisexual women were satisfied with the health and social services that they received during the process of trying to conceive, during pregnancy, and during the early postpartum weeks and months. Three focus groups were conducted: (1) women who were themselves, or whose partners were, in the process of trying to conceive (n = 6); (2) biological parents of young children (n = 7); and (3) women who were non-biological parents of young children or whose partners were currently pregnant (n = 10). Participants were asked to discuss their positive and negative experiences with health and social services during their efforts to conceive and through the perinatal period. Participants were very satisfied with the care they received from midwives, doulas, and public health nurses. Services directed specifically to lesbian, gay, and bisexual parents were also perceived to be important sources of information and support. Many participants perceived fertility services to be unsupportive or unable to address their different health care needs. Participants expressed satisfaction with pregnancy-related services provided by non-physicians and dissatisfaction with services provided by physicians and fertility clinics. There is a strong desire for fertility services specific to lesbian and bisexual women, but even minor changes to existing services could improve the satisfaction of lesbian and bisexual patients.
To date, there is little evidence to inform social work practice with lesbian and bisexual women ... more To date, there is little evidence to inform social work practice with lesbian and bisexual women who are trying to conceive (TTC). The authors report a preliminary examination of the mental health experiences of lesbian and bisexual women who are TTC, through a comparison with lesbian and bisexual women in the postpartum period (PP). Thirty-three lesbian and bisexual women (TTC, n = 15; PP, n = 18) completed standardized questionnaires assessing symptoms of depression and anxiety as well as relationship satisfaction and perceived social support. Qualitative interviews were also conducted to further investigate the experience of TTC. No significant differences were found between groups on any of the dependent variables. Analysis of qualitative data highlighted the challenges for lesbian and bisexual women who are TTC, particularly in terms of difficulty conceiving, lack of support during the conception process, and heterosexism in the fertility system. Women perceived these challenges to conception as having emotional consequences. The findings from this study begin to elucidate the unique context of TTC for lesbian and bisexual women, and they highlight the importance of culturally competent social work practice with this population.
Lesbian, gay, and bisexual women undertake parenting in a social context that may be associated w... more Lesbian, gay, and bisexual women undertake parenting in a social context that may be associated with unique risk factors for perinatal depression. This cross-sectional study aimed to describe the mental health services used by women in the perinatal period and to identify potential correlates of mental health service use. Sixty-four women who were currently trying to conceive, pregnant, or the parent of a child less than one year of age were included. One-third of women reported some mental health service use within the past year; 30.6% of women reported a perceived unmet need for mental health services in the past year, with 40% of these women citing financial barriers as the reason for their unmet need. Women who were trying to get pregnant or who were less &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;out&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; were most likely to have had recent mental health service use. Women who had conceived by having sex with a man or who reported more than three episodes of discrimination were most likely to report unmet needs for mental health services. Providers may benefit from additional knowledge about the LBG social context that is relevant to perinatal health, and from identifying a strong referral network of skilled and affordable counsellors.
Feminisms in Social Work Research Promise and possibilities for justice-based knowledge .
In this chapter, we examine our engagement with critical feminism in research within the context ... more In this chapter, we examine our engagement with critical feminism in research within the context of an ongoing critical, collaborative, and interdisciplinary research project. We speak from our respective social identities and locations to explore feminist research issues including epistemology, collaborative methodology and representation, ethics, collaborative knowledge production, and communication with relevant audiences. Throughout the chapter we contextualize our reflections in current debates within both feminist and service user research literature as informed by the disability rights and consumer/survivor (C/S) movements.
Objective: The lesbian patient population is underserved. Almost no research has examined the kno... more Objective: The lesbian patient population is underserved. Almost no research has examined the knowledge and attitudes of obstetrician-gynecologists toward lesbian health. Our study sought to address this research gap. Methods: All 910 obstetrician-gynecologists licensed in Ontario, Canada, were mailed a true-false survey about lesbian health issues, the Homosexuality Attitudes Scale (HAS), and a demographic survey. Results: Of the 910 surveys, 271 were returned. The mean HAS score was 87.6 (standard deviation [SD] 11.5), indicating an overall positive attitude. The mean knowledge score was 76.0% (SD 9.5), indicating that respondents had adequate knowledge about lesbian health; 22% described their lesbian health knowledge-base as unaware. Most respondents reported lack of education on lesbian health in residency (81%) or medical school (78%). The majority reported a desire for formal education pertaining to lesbian health. There was no correlation between HAS and knowledge scores. Conclusions: Although our results indicate overall adequate knowledge about lesbian health issues, important knowledge gaps were identified. Medical school and residency training curricula should include formal education about lesbian health issues, particularly because most obstetrician-gynecologists report a desire to receive this information.
Objective: To determine what recommendations lesbian, gay, bisexual, trans, and queer (LGBTQ) peo... more Objective: To determine what recommendations lesbian, gay, bisexual, trans, and queer (LGBTQ) people have for provision of assisted human reproduction (AHR) services to their communities.
Methods: Using a semi-structured guide, we interviewed a purposeful sample of 66 LGBTQ-identified individuals from across the province of Ontario who had used or had considered using AHR services since 2007.
Results: Participants were predominately cisgender (non-trans), white, same-sex partnered, urban women with relatively high levels of education and income. Participants made recommendations for changes to the following aspects of AHR service provision: (1) access to LGBTQ-relevant information, (2) adoption of patient-centred practices by AHR service providers, (3) training and education of service providers regarding LGBTQ issues and needs, (4) increased visibility of LGBTQ people in clinic environments, and (5) attention to service gaps of particular concern to LGBTQ people.
Conclusion: Many of the recommendations made by study participants show how patient-centred models may address inequities in service delivery for LGBTQ people and for other patients who may have particular AHR service needs. Our results suggest that service providers need education to enact these patient-centred practices and to deliver equitable care to LGBTQ patients.
Objective: To determine the effectiveness of interactive theatre as a knowledge translation and e... more Objective: To determine the effectiveness of interactive theatre as a knowledge translation and exchange (KTE) method to educate assisted human reproduction (AHR) service providers about lesbian, gay, bisexual, trans and queer (LGBTQ) patients.
Design: We transformed data from the ‘Creating Our Families’ study, a qualitative, community-based study of LGBTQ peoples’ experiences accessing AHR services, into a script for an interactive theatre workshop for AHR service providers. Based on forum theatre principles, our workshop included five scenes illustrating LGBTQ people interacting with service providers, followed by audience interventions to these scenes. Before and after the workshop, service providers completed surveys to assess their knowledge and comfort concerning LGBTQ patients, as well as the modality of the interactive theatre workshop as a KTE strategy. Wilcoxon signed-rank tests were used to determine changes in preworkshop and postworkshop knowledge and comfort scores.
Results: Thirty AHR service providers attended the workshop. Twenty-three service providers (76.7%) fully completed the preworkshop and postworkshop evaluation forms. Service providers’ knowledge scores significantly improved after the workshop, while their comfort scores minimally decreased. Most agreed that the interactive workshop was an effective KTE method.
Conclusions: In comparison with traditional forms of KTE, interactive theatre may be particularly effective in engaging service providers and addressing their attitudes towards marginalised patient populations. Although the evaluation results of our interactive workshop were mostly positive, the long-term impact of the workshop is unknown. Long-term evaluations are needed to determine the effectiveness of arts-based KTE efforts. Other considerations for developing effective arts-based KTE strategies include adequate funding, institutional support, attention to power dynamics and thoughtful collaboration with forum theatre experts.
PURPOSE:
Few studies have examined the role of culture in a woman's experience of postpartum moo... more PURPOSE:
Few studies have examined the role of culture in a woman's experience of postpartum mood problems (PPMP). This study explored differences and similarities in experiences of PPMP between first- and second-generation Canadian women.
DESIGN:
In this exploratory qualitative study, we interviewed nine first-generation and eight second-generation women who were clients of the Women's Health Centre at St. Joseph's Health Centre in Toronto, Canada. Using semistructured interviews, we explored how women perceived and experienced PPMP.
FINDINGS:
Four themes reflected cultural issues: PPMP stigma, relationship with parents/in-laws, internalization of society's expectations of motherhood, and identity issues/relationship with self.
DISCUSSION:
The results of this study contribute to a limited literature on possible contributing factors to PPMP and can inform development of resources for delivering culturally appropriate mental health care for women dealing with PPMP.
IMPORTANCE:
Untreated depression during pregnancy has been associated with increased morbidity an... more IMPORTANCE: Untreated depression during pregnancy has been associated with increased morbidity and mortality for both mother and child and, as such, optimal treatment strategies are required for this population. CONTEXT: There are conflicting data regarding potential risks of prenatal antidepressant treatment. OBJECTIVE: To determine whether prenatal antidepressant exposure is associated with risk for selected adverse pregnancy or delivery outcomes. DATA SOURCES MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library were searched from their start dates to June 30, 2010. STUDY SELECTION English-language studies reporting outcomes associated with pharmacologic treatment during pregnancy were included. We reviewed 3074 abstracts, retrieved 735 articles, and included 23 studies in this meta-analysis. DATA EXTRACTION: Study design, antidepressant exposure, adjustment for confounders, and study quality were extracted by 2 independent reviewers. RESULTS: There was no significant association between antidepressant medication exposure and spontaneous abortion (odds ratio [OR], 1.47; 95% CI, 0.99 to 2.17; P = .055). Gestational age and preterm delivery were statistically significantly associated with antidepressant exposure (mean difference [MD] [weeks], -0.45; 95% CI, -0.64 to -0.25; P < .001; and OR, 1.55; 95% CI, 1.38 to 1.74; P < .001, respectively), regardless of whether the comparison group consisted of all unexposed mothers or only depressed mothers without antidepressant exposure. Antidepressant exposure during pregnancy was significantly associated with lower birth weight (MD [grams], -74; 95% CI, -117 to -31; P = .001); when this comparison group was limited to depressed mothers without antidepressant exposure, there was no longer a significant association. Antidepressant exposure was significantly associated with lower Apgar scores at 1 and 5 minutes, regardless of whether the comparison group was all mothers or only those who were depressed during pregnancy but not exposed to antidepressants. CONCLUSIONS AND RELEVANCE: Although statistically significant associations between antidepressant exposure and pregnancy and delivery outcomes were identified, group differences were small and scores in the exposed group were typically within the normal ranges, indicating the importance of considering clinical significance. Treatment decisions must weigh the effect of untreated maternal depression against the potential adverse effects of antidepressant exposure.
OBJECTIVE:
Depression is often not optimally treated during pregnancy, partially because of confl... more OBJECTIVE: Depression is often not optimally treated during pregnancy, partially because of conflicting data regarding antidepressant medication risk. This meta-analysis was conducted to determine whether antenatal antidepressant exposure is associated with congenital malformations and to assess the effect of known methodological limitations. DATA SOURCES: EMBASE, CINAHL, PsycINFO, and MEDLINE were searched from their start dates to June 2010. Keywords of various combinations were used, including, but not limited to depressive/mood disorder, pregnancy, antidepressant drug/agent, congenital malformation, and cardiac malformation. STUDY SELECTION: English language studies reporting congenital malformations associated with antidepressants were included. Of 3,074 abstracts reviewed, 735 studies were retrieved and 27 studies were included. DATA EXTRACTION: Two reviewers working independently assessed article quality. Data on use of any antidepressant, including fluoxetine and paroxetine specifically, were extracted. Outcomes included congenital malformations, major congenital malformations, cardiovascular defects, septal heart defects (ventral septal defects and atrial septal defects), and ventral septal defects only. RESULTS: Nineteen studies were above quality threshold and make up the primary meta-analyses. Pooled relative risks (RRs) were derived by using random-effects methods. Antidepressant exposure was not associated with congenital malformations (RR = 0.93; 95% CI, 0.85-1.02; P = .113) or major malformations (RR = 1.07; 95% CI, 0.99-1.17; P = .095). However, increased risk for cardiovascular malformations (RR = 1.36; 95% CI, 1.08-1.71; P = .008) and septal heart defects (RR = 1.40; 95% CI, 1.10-1.77; P = .005) were found; the RR for ventral septal defects was similar to septal defects, although not significant (RR = 1.54; 95% CI, 0.71-3.33; P = .274). Pooled effects were significant for paroxetine and cardiovascular malformations (RR = 1.43; 95% CI, 1.08-1.88; P = .012). These results are contrasted with those addressing methodological limitations but are typically consistent. CONCLUSIONS: Overall, antidepressants do not appear to be associated with an increased risk of congenital malformations, but statistical significance was found for cardiovascular malformations. Results were robust in several sensitivity analyses. Given that the RRs are marginal, they may be the result of uncontrolled confounders. Although the RRs were statistically significant, none reached clinically significant levels.
Work has been underway to increase the availability of parenting options for people living with a... more Work has been underway to increase the availability of parenting options for people living with and affected by HIV. One option, adoption, has not yet been explored in the literature. The study aimed to gain a better understanding of the potential of adoption for individuals/couples living with HIV in Ontario, and to assess potential structural barriers or facilitators that may impact their experience navigating the adoption system by conducting an environmental scan of adoption service providers in Ontario. A list of adoption service providers was compiled using the Ontario government’s website. Information relevant to the study’s measures was collected using service providers’ websites. Service providers without websites, or with websites that did not address all of the research measures, were contacted via telephone to complete a structured interview. Online data extraction was possible for 2 and telephone surveys were completed with 75 adoption service providers (total n = 77). Most service providers reported that HIV status is not an exclusion criterion for prospective parents (64%). However, more than one-fifth of the participants acknowledged they were not sure if people with HIV were eligible to adopt. Domestic service providers were the only providers who did not report knowledge of restrictions due to HIV status. Private domestic adoption presented social barriers as birth parent(s) of a child can access health records of a prospective parent and base their selection of an adoptive parent based on health status. Adoption practitioners and licensees involved in international adoptions reported the most structural barriers for prospective parent(s) living with HIV, attributed to the regulations established by the host country of the child(ren) eligible for adoption. Although international adoptions may present insurmountable barriers for individuals living with HIV, public and private domestic adoption appears to be a viable option.
Bisexuality is consistently associated with poor mental health outcomes. In population-based data... more Bisexuality is consistently associated with poor mental health outcomes. In population-based data, this is partially explained by income differences between bisexual people and lesbian, gay, and/or heterosexual individuals. However, the interrelationships between bisexuality, poverty, and mental health are poorly understood. In this paper, we examine the relationships between these variables using a mixed methods study of 302 adult bisexuals from Ontario, Canada. Participants were recruited using respondent-driven sampling to complete an internet-based survey including measures of psychological distress and minority stress. A subset of participants completed a semi-structured qualitative interview to contextualize their mental health experiences. Using information regarding household income, number of individuals supported by the income and geographic location, participants were categorized as living below or above the Canadian Low Income Cut Off (LICO). Accounting for the networked nature of the sample, participants living below the LICO had significantly higher mean scores for depression and posttraumatic stress disorder symptoms and reported significantly more perceived discrimination compared to individuals living above the LICO. Grounded theory analysis of the qualitative interviews suggested four pathways through which bisexuality and poverty may intersect to impact mental health: through early life experiences linked to bisexuality or poverty that impacted future financial stability; through effects of bisexual identity on employment and earning potential; through the impact of class and sexual orientation discrimination on access to communities of support; and through lack of access to mental health services that could provide culturally competent care. These mixed methods data help us understand the income disparities associated with bisexual identity in population-based data, and suggest points of intervention to address their impact on bisexual mental health.
There is increasing attention to diversity in psy- chiatric services and widespread recognition o... more There is increasing attention to diversity in psy- chiatric services and widespread recognition of the mental health implications of stigma for individuals from sexual or gender minority groups. A review of the literature was conducted to answer the following question: What factors and strategies need to be considered when developing services for individuals from sexual or gender minority groups who are experiencing severe mental illness? A total of 27 publications were identified for review. Mental health services research indicated generally lower levels of service satisfaction among lesbian, gay, bisexual, transgender, and transsexual (LGBT) individuals and minimal evidence regarding specific interventions. There is a pressing need for research into in- terventions for LGBT populations with severe mental illness as well as descriptive studies to inform efforts to reduce ill- ness morbidity linked to discrimination.
Bisexuals are at greater risk for poor mental health compared with heterosexual, gay, and lesbian... more Bisexuals are at greater risk for poor mental health compared with heterosexual, gay, and lesbian people. This increased risk has been attributed to biphobia yet the relationship between biphobia and mental health has been understudied. Data were collected from an Ontario-wide survey of bisexuals, broadly defined, using respondent-driven sampling (N = 405), and minority stress theory was applied to examine the relationship between biphobia (from the straight community and gay/lesbian community separately) and anxiety using structural equation modelling. In contrast to our hypothesis, biphobia had little impact on anxiety. Results suggest that we need to enhance our capacity to measure discrimination.
Research suggests an elevated level of posttraumatic stress disorder (PTSD) among bisexuals. The ... more Research suggests an elevated level of posttraumatic stress disorder (PTSD) among bisexuals. The PTSD Checklist–Civilian version (PCL-C) is a self-report measure used to assess PTSD symptoms in nonmilitary persons, closely following Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. In a study of 405 bisexuals in Ontario, Canada, the authors evaluated the PCL-C using confirmatory factor analysis and found it performed poorly. The authors caution researchers to be aware of the PCL-C's limitations. The authors concur that the three symptom clusters may not be the best way to evaluate the presence of PTSD, an issue that may be alleviated with PCL-C revisions to align with DSM-V criteria.
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Papers by Lori Ross
of poor mental health outcomes compared to both heterosexual and gay/lesbian individuals. However,
no previous meta-analyses have been conducted to establish the magnitude of these disparities. To
address this research gap, we conducted a systematic review and meta-analysis of studies that reported
bisexual-specific data on standardized measures of depression or anxiety. Of the 1,074 full-text articles
reviewed, 1,023 were ineligible, predominantly because they did not report separate data for bisexual
people (n = 562 studies). Ultimately, 52 eligible studies could be pooled in the analysis. Results indicate
that across both outcomes, there is a consistent pattern of lowest rates of depression and anxiety among
heterosexual people, while bisexual people exhibit higher or equivalent rates in comparison to lesbian/
gay people. On the basis of empirical and theoretical literature, we propose three interrelated contributors
to these disparities: experiences of sexual orientation-based discrimination, bisexual invisibility/erasure,
and lack of bisexual-affirmative support. Implications for interventions to improve the
health and well-being of bisexual people are proposed.
Methods: Using a semi-structured guide, we interviewed a purposeful sample of 66 LGBTQ-identified individuals from across the province of Ontario who had used or had considered using AHR services since 2007.
Results: Participants were predominately cisgender (non-trans), white, same-sex partnered, urban women with relatively high levels of education and income. Participants made recommendations for changes to the following aspects of AHR service provision: (1) access to LGBTQ-relevant information, (2) adoption of patient-centred practices by AHR service providers, (3) training and education of service providers regarding LGBTQ issues and needs, (4) increased visibility of LGBTQ people in clinic environments, and (5) attention to service gaps of particular concern to LGBTQ people.
Conclusion: Many of the recommendations made by study participants show how patient-centred models may address inequities in service delivery for LGBTQ people and for other patients who may have particular AHR service needs. Our results suggest that service providers need education to enact these patient-centred practices and to deliver equitable care to LGBTQ patients.
Design: We transformed data from the ‘Creating Our Families’ study, a qualitative, community-based study of LGBTQ peoples’ experiences accessing AHR services, into a script for an interactive theatre workshop for AHR service providers. Based on forum theatre principles, our workshop included five scenes illustrating LGBTQ people interacting with service providers, followed by audience interventions to these scenes. Before and after the workshop, service providers completed surveys to assess their knowledge and comfort concerning LGBTQ patients, as well as the modality of the interactive theatre workshop as a KTE strategy. Wilcoxon signed-rank tests were used to determine changes in preworkshop and postworkshop knowledge and comfort scores.
Results: Thirty AHR service providers attended the workshop. Twenty-three service providers (76.7%) fully completed the preworkshop and postworkshop evaluation forms. Service providers’ knowledge scores significantly improved after the workshop, while their comfort scores minimally decreased. Most agreed that the interactive workshop was an effective KTE method.
Conclusions: In comparison with traditional forms of KTE, interactive theatre may be particularly effective in engaging service providers and addressing their attitudes towards marginalised patient populations. Although the evaluation results of our interactive workshop were mostly positive, the long-term impact of the workshop is unknown. Long-term evaluations are needed to determine the effectiveness of arts-based KTE efforts. Other considerations for developing effective arts-based KTE strategies include adequate funding, institutional support, attention to power dynamics and thoughtful collaboration with forum theatre experts.
Few studies have examined the role of culture in a woman's experience of postpartum mood problems (PPMP). This study explored differences and similarities in experiences of PPMP between first- and second-generation Canadian women.
DESIGN:
In this exploratory qualitative study, we interviewed nine first-generation and eight second-generation women who were clients of the Women's Health Centre at St. Joseph's Health Centre in Toronto, Canada. Using semistructured interviews, we explored how women perceived and experienced PPMP.
FINDINGS:
Four themes reflected cultural issues: PPMP stigma, relationship with parents/in-laws, internalization of society's expectations of motherhood, and identity issues/relationship with self.
DISCUSSION:
The results of this study contribute to a limited literature on possible contributing factors to PPMP and can inform development of resources for delivering culturally appropriate mental health care for women dealing with PPMP.
Untreated depression during pregnancy has been associated with increased morbidity and mortality for both mother and child and, as such, optimal treatment strategies are required for this population.
CONTEXT:
There are conflicting data regarding potential risks of prenatal antidepressant treatment.
OBJECTIVE:
To determine whether prenatal antidepressant exposure is associated with risk for selected adverse pregnancy or delivery outcomes. DATA SOURCES MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library were searched from their start dates to June 30, 2010. STUDY SELECTION English-language studies reporting outcomes associated with pharmacologic treatment during pregnancy were included. We reviewed 3074 abstracts, retrieved 735 articles, and included 23 studies in this meta-analysis.
DATA EXTRACTION:
Study design, antidepressant exposure, adjustment for confounders, and study quality were extracted by 2 independent reviewers.
RESULTS:
There was no significant association between antidepressant medication exposure and spontaneous abortion (odds ratio [OR], 1.47; 95% CI, 0.99 to 2.17; P = .055). Gestational age and preterm delivery were statistically significantly associated with antidepressant exposure (mean difference [MD] [weeks], -0.45; 95% CI, -0.64 to -0.25; P < .001; and OR, 1.55; 95% CI, 1.38 to 1.74; P < .001, respectively), regardless of whether the comparison group consisted of all unexposed mothers or only depressed mothers without antidepressant exposure. Antidepressant exposure during pregnancy was significantly associated with lower birth weight (MD [grams], -74; 95% CI, -117 to -31; P = .001); when this comparison group was limited to depressed mothers without antidepressant exposure, there was no longer a significant association. Antidepressant exposure was significantly associated with lower Apgar scores at 1 and 5 minutes, regardless of whether the comparison group was all mothers or only those who were depressed during pregnancy but not exposed to antidepressants.
CONCLUSIONS AND RELEVANCE:
Although statistically significant associations between antidepressant exposure and pregnancy and delivery outcomes were identified, group differences were small and scores in the exposed group were typically within the normal ranges, indicating the importance of considering clinical significance. Treatment decisions must weigh the effect of untreated maternal depression against the potential adverse effects of antidepressant exposure.
Depression is often not optimally treated during pregnancy, partially because of conflicting data regarding antidepressant medication risk. This meta-analysis was conducted to determine whether antenatal antidepressant exposure is associated with congenital malformations and to assess the effect of known methodological limitations.
DATA SOURCES:
EMBASE, CINAHL, PsycINFO, and MEDLINE were searched from their start dates to June 2010. Keywords of various combinations were used, including, but not limited to depressive/mood disorder, pregnancy, antidepressant drug/agent, congenital malformation, and cardiac malformation.
STUDY SELECTION:
English language studies reporting congenital malformations associated with antidepressants were included. Of 3,074 abstracts reviewed, 735 studies were retrieved and 27 studies were included.
DATA EXTRACTION:
Two reviewers working independently assessed article quality. Data on use of any antidepressant, including fluoxetine and paroxetine specifically, were extracted. Outcomes included congenital malformations, major congenital malformations, cardiovascular defects, septal heart defects (ventral septal defects and atrial septal defects), and ventral septal defects only.
RESULTS:
Nineteen studies were above quality threshold and make up the primary meta-analyses. Pooled relative risks (RRs) were derived by using random-effects methods. Antidepressant exposure was not associated with congenital malformations (RR = 0.93; 95% CI, 0.85-1.02; P = .113) or major malformations (RR = 1.07; 95% CI, 0.99-1.17; P = .095). However, increased risk for cardiovascular malformations (RR = 1.36; 95% CI, 1.08-1.71; P = .008) and septal heart defects (RR = 1.40; 95% CI, 1.10-1.77; P = .005) were found; the RR for ventral septal defects was similar to septal defects, although not significant (RR = 1.54; 95% CI, 0.71-3.33; P = .274). Pooled effects were significant for paroxetine and cardiovascular malformations (RR = 1.43; 95% CI, 1.08-1.88; P = .012). These results are contrasted with those addressing methodological limitations but are typically consistent.
CONCLUSIONS:
Overall, antidepressants do not appear to be associated with an increased risk of congenital malformations, but statistical significance was found for cardiovascular malformations. Results were robust in several sensitivity analyses. Given that the RRs are marginal, they may be the result of uncontrolled confounders. Although the RRs were statistically significant, none reached clinically significant levels.
of poor mental health outcomes compared to both heterosexual and gay/lesbian individuals. However,
no previous meta-analyses have been conducted to establish the magnitude of these disparities. To
address this research gap, we conducted a systematic review and meta-analysis of studies that reported
bisexual-specific data on standardized measures of depression or anxiety. Of the 1,074 full-text articles
reviewed, 1,023 were ineligible, predominantly because they did not report separate data for bisexual
people (n = 562 studies). Ultimately, 52 eligible studies could be pooled in the analysis. Results indicate
that across both outcomes, there is a consistent pattern of lowest rates of depression and anxiety among
heterosexual people, while bisexual people exhibit higher or equivalent rates in comparison to lesbian/
gay people. On the basis of empirical and theoretical literature, we propose three interrelated contributors
to these disparities: experiences of sexual orientation-based discrimination, bisexual invisibility/erasure,
and lack of bisexual-affirmative support. Implications for interventions to improve the
health and well-being of bisexual people are proposed.
Methods: Using a semi-structured guide, we interviewed a purposeful sample of 66 LGBTQ-identified individuals from across the province of Ontario who had used or had considered using AHR services since 2007.
Results: Participants were predominately cisgender (non-trans), white, same-sex partnered, urban women with relatively high levels of education and income. Participants made recommendations for changes to the following aspects of AHR service provision: (1) access to LGBTQ-relevant information, (2) adoption of patient-centred practices by AHR service providers, (3) training and education of service providers regarding LGBTQ issues and needs, (4) increased visibility of LGBTQ people in clinic environments, and (5) attention to service gaps of particular concern to LGBTQ people.
Conclusion: Many of the recommendations made by study participants show how patient-centred models may address inequities in service delivery for LGBTQ people and for other patients who may have particular AHR service needs. Our results suggest that service providers need education to enact these patient-centred practices and to deliver equitable care to LGBTQ patients.
Design: We transformed data from the ‘Creating Our Families’ study, a qualitative, community-based study of LGBTQ peoples’ experiences accessing AHR services, into a script for an interactive theatre workshop for AHR service providers. Based on forum theatre principles, our workshop included five scenes illustrating LGBTQ people interacting with service providers, followed by audience interventions to these scenes. Before and after the workshop, service providers completed surveys to assess their knowledge and comfort concerning LGBTQ patients, as well as the modality of the interactive theatre workshop as a KTE strategy. Wilcoxon signed-rank tests were used to determine changes in preworkshop and postworkshop knowledge and comfort scores.
Results: Thirty AHR service providers attended the workshop. Twenty-three service providers (76.7%) fully completed the preworkshop and postworkshop evaluation forms. Service providers’ knowledge scores significantly improved after the workshop, while their comfort scores minimally decreased. Most agreed that the interactive workshop was an effective KTE method.
Conclusions: In comparison with traditional forms of KTE, interactive theatre may be particularly effective in engaging service providers and addressing their attitudes towards marginalised patient populations. Although the evaluation results of our interactive workshop were mostly positive, the long-term impact of the workshop is unknown. Long-term evaluations are needed to determine the effectiveness of arts-based KTE efforts. Other considerations for developing effective arts-based KTE strategies include adequate funding, institutional support, attention to power dynamics and thoughtful collaboration with forum theatre experts.
Few studies have examined the role of culture in a woman's experience of postpartum mood problems (PPMP). This study explored differences and similarities in experiences of PPMP between first- and second-generation Canadian women.
DESIGN:
In this exploratory qualitative study, we interviewed nine first-generation and eight second-generation women who were clients of the Women's Health Centre at St. Joseph's Health Centre in Toronto, Canada. Using semistructured interviews, we explored how women perceived and experienced PPMP.
FINDINGS:
Four themes reflected cultural issues: PPMP stigma, relationship with parents/in-laws, internalization of society's expectations of motherhood, and identity issues/relationship with self.
DISCUSSION:
The results of this study contribute to a limited literature on possible contributing factors to PPMP and can inform development of resources for delivering culturally appropriate mental health care for women dealing with PPMP.
Untreated depression during pregnancy has been associated with increased morbidity and mortality for both mother and child and, as such, optimal treatment strategies are required for this population.
CONTEXT:
There are conflicting data regarding potential risks of prenatal antidepressant treatment.
OBJECTIVE:
To determine whether prenatal antidepressant exposure is associated with risk for selected adverse pregnancy or delivery outcomes. DATA SOURCES MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library were searched from their start dates to June 30, 2010. STUDY SELECTION English-language studies reporting outcomes associated with pharmacologic treatment during pregnancy were included. We reviewed 3074 abstracts, retrieved 735 articles, and included 23 studies in this meta-analysis.
DATA EXTRACTION:
Study design, antidepressant exposure, adjustment for confounders, and study quality were extracted by 2 independent reviewers.
RESULTS:
There was no significant association between antidepressant medication exposure and spontaneous abortion (odds ratio [OR], 1.47; 95% CI, 0.99 to 2.17; P = .055). Gestational age and preterm delivery were statistically significantly associated with antidepressant exposure (mean difference [MD] [weeks], -0.45; 95% CI, -0.64 to -0.25; P < .001; and OR, 1.55; 95% CI, 1.38 to 1.74; P < .001, respectively), regardless of whether the comparison group consisted of all unexposed mothers or only depressed mothers without antidepressant exposure. Antidepressant exposure during pregnancy was significantly associated with lower birth weight (MD [grams], -74; 95% CI, -117 to -31; P = .001); when this comparison group was limited to depressed mothers without antidepressant exposure, there was no longer a significant association. Antidepressant exposure was significantly associated with lower Apgar scores at 1 and 5 minutes, regardless of whether the comparison group was all mothers or only those who were depressed during pregnancy but not exposed to antidepressants.
CONCLUSIONS AND RELEVANCE:
Although statistically significant associations between antidepressant exposure and pregnancy and delivery outcomes were identified, group differences were small and scores in the exposed group were typically within the normal ranges, indicating the importance of considering clinical significance. Treatment decisions must weigh the effect of untreated maternal depression against the potential adverse effects of antidepressant exposure.
Depression is often not optimally treated during pregnancy, partially because of conflicting data regarding antidepressant medication risk. This meta-analysis was conducted to determine whether antenatal antidepressant exposure is associated with congenital malformations and to assess the effect of known methodological limitations.
DATA SOURCES:
EMBASE, CINAHL, PsycINFO, and MEDLINE were searched from their start dates to June 2010. Keywords of various combinations were used, including, but not limited to depressive/mood disorder, pregnancy, antidepressant drug/agent, congenital malformation, and cardiac malformation.
STUDY SELECTION:
English language studies reporting congenital malformations associated with antidepressants were included. Of 3,074 abstracts reviewed, 735 studies were retrieved and 27 studies were included.
DATA EXTRACTION:
Two reviewers working independently assessed article quality. Data on use of any antidepressant, including fluoxetine and paroxetine specifically, were extracted. Outcomes included congenital malformations, major congenital malformations, cardiovascular defects, septal heart defects (ventral septal defects and atrial septal defects), and ventral septal defects only.
RESULTS:
Nineteen studies were above quality threshold and make up the primary meta-analyses. Pooled relative risks (RRs) were derived by using random-effects methods. Antidepressant exposure was not associated with congenital malformations (RR = 0.93; 95% CI, 0.85-1.02; P = .113) or major malformations (RR = 1.07; 95% CI, 0.99-1.17; P = .095). However, increased risk for cardiovascular malformations (RR = 1.36; 95% CI, 1.08-1.71; P = .008) and septal heart defects (RR = 1.40; 95% CI, 1.10-1.77; P = .005) were found; the RR for ventral septal defects was similar to septal defects, although not significant (RR = 1.54; 95% CI, 0.71-3.33; P = .274). Pooled effects were significant for paroxetine and cardiovascular malformations (RR = 1.43; 95% CI, 1.08-1.88; P = .012). These results are contrasted with those addressing methodological limitations but are typically consistent.
CONCLUSIONS:
Overall, antidepressants do not appear to be associated with an increased risk of congenital malformations, but statistical significance was found for cardiovascular malformations. Results were robust in several sensitivity analyses. Given that the RRs are marginal, they may be the result of uncontrolled confounders. Although the RRs were statistically significant, none reached clinically significant levels.