Cecilia T. Hardacker

We appreciate your comments and concerns about our manuscript in IJERPH on Bladder Health Experiences, Perceptions and Knowledge of Sexual and Gender Minorities

The World Health Organization recognizes access to clean and safe toilets as crucial for public health. This study explored U.S. adolescent and adult cisgender women’s lived experiences accessing toilets in schools, workplaces, and public spaces. As part of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, we conducted 44 focus groups with female participants (n = 360; ages 11–93). Focus groups were stratified by age (11–14, 15–17, 18–25, 26–44, 45–64, 65+) and conducted across 7 geographically diverse U.S. sites from July 2017–April 2018. Using a transdisciplinary approach, we conducted conventional qualitative coding informed by our PLUS conceptual framework and used content analysis processes to identify salient themes. Across settings, toilet access was restricted by “gatekeepers” (i.e., individuals who control access to toilets). In contrast, self-restricting toilet use (deciding not to use the toilet despite biologic need to urinate) was based on internalized norms to prioritize school and job responsibilities over urination. In public spaces, self-restricting use was largely in response to lack of cleanliness. Across the life course, participants perceived gender disparities in the ability to easily access public toilets. Further research is needed to determine if and how these factors impact bladder health across the life course.

While recent efforts have been made to understand the bladder health experiences, perceptions, and knowledge of cisgender adolescent females and women, virtually nothing is known about the bladder health experiences of people who identify as sexual and gender minorities (SGMs). A community-based participatory research approach using a focus group methodology to engage 36 adult participants who identify as SGM, including individuals who identify as gender non-conforming, queer, transgender (trans) men, or lesbian, in one of six focus group discussions on bladder health. Using directed content qualitative data analysis from the six unique focus groups, three interrelated themes were revealed: gender socialization of voiding behavior and toilet environment culture producing identity threats, and risks to gender affirmation; consequences of hetero-cis normative bathroom infrastructure necessitating adaptive voiding behaviors; and, physical and psychosocial consequences of chronic anxiety and fear are associated with voiding experiences. Insight on how SGMs navigate voiding behaviors, toilet experiences, and health care seeking is needed to assure that bladder health promotion activities are inclusive of this population’s needs.

In 2009, the Howard Brown Health Center received funding from the US Department of Health and Human Services, and Health Resources and Services Administration to develop and disseminate a peer-reviewed, six-module curriculum entitled, Health Education about LGBT (lesbian, gay, bisexual and transgender) Elders (HEALE). The HEALE curriculum targets nurses and health-care staff and is focused on the treatment of LGBT elders, a population that is largely misunderstood and discriminated against in health-care settings. The HEALE curriculum was presented in hospital academic centres, community-based clinics and nursing homes over a three-year period, and training staff provided education to over 500 nurses and health-care providers. A pre-test and post-test was administered to participants, and all data were collected and archived to measure knowledge gained. Participants also completed an evaluation at the conclusion of the training to report change in personal attitude and individual response to the curriculum. From March 2011 to June 2012, 848 individuals attended HEALE curriculum sessions at 23 locations in Chicago and surrounding areas. Participants were 40% white, 25% black, 9% Hispanic/Latino and 25% Asian race/ethnicity. The majority of participants were female and approximately 25% were under the age of 30 years. There were statistically significant gains in knowledge in each of the six modules both in nursing home/home health-care settings and in hospital/educational settings, although participants in nursing home/home health care settings had lower pre-test scores and smaller knowledge gains in each of the six modules than those in hospital/educational settings. Mean increases ranged from 6.4 points (an 8.7% increase) in module 1-14.6 points (a 26.2% increase) in Module 6 (P < 0.01). The HEALE curriculum sets a standard for best practices in nursing management and for LGBT cultural competency in geriatric education. As such, implementation of this cultural competency training will go a long way to establish fundamental concepts regarding LGBT elder care and provide long-term strategies for providing culturally sensitive patient care.