Profound health-care discrimination experienced by transgender people: rapid systematic review

Compelling care: A grounded theory of transmasculine self-defense and collective protection at the clinic

Despite formidable inequities in health care systems, transgender people are accessing clinical services in record numbers and gaining recognition as a patient population. This article examines how transgender people are negotiating their care and, in so doing, challenging patterns of marginalization and exclusion. Interviews with twenty-six transmasculine adults were collected and analyzed in the context of a community-led initiative foregrounding low-income people and people of color in Los Angeles County using a constructivist grounded theory approach. Participants gained agency in clinical settings by compelling care, a grounded theory that explains how patients contest medical authority and shift power through everyday acts to defend themselves and future patients. Histories of mistreatment and unequal social power drive patients to engage with health care providers judiciously and with a sense of social responsibility. In tracing seemingly decentralized acts of self-defense (e.g., vetting providers, disrupting gender norms, directing treatment), the study shows how patients rely on community resources and marshal collective protection. The theory recasts patients as constitutive actors in a changing landscape of care and as integral to, and one of many fronts of, collective struggle. In turn, the study lends theoretical insights to anti-racist understandings of medical mistrust andoffers a depathologized framework toward the development of community-building health equity interventions.

Two Gender Medicine: Provider-Side Barriers to Caring for Transgender and Gender Diverse Patients

Experienced and anticipated discrimination during health care visits result in lower health care utilization rates, which contribute to persistent health disparities between transgender and gender diverse (TGD) individuals and the general population. Most strategies for improving health care delivery to TGD patients place the responsibility on providers, overlooking the role of medical systems and institutions in creating the environments where negative health care experiences occur. Relying on the inhabited institutionalism framework, this study explores system- and institutional-level barriers to the provision of quality care to TGD patients identified by health care providers and administrators, including relevant contextual details of, and interactions between, these barriers. Based on interview data from health care providers and administrators from a variety of practices across Texas, we identified two overarching themes and six subthemes. We demonstrate how our interviewees' responses reveal an institutional logic of "two-gender medicine," which creates barriers to health care provision in both formal medical education and training and throughout the managed care model of practice. We also illustrate how health care workers find ways to resist this logic in the course of their practice. Addressing these barriers to delivering competent and compassionate care to TGD patients that providers encounter could make long overdue strides toward addressing health disparities.

Intention to Use Different Formulations of Longer Acting HIV Pre-Exposure Prophylaxis Among Transgender and Gender Expansive Individuals: The Roles of Social Vulnerability and Medical Mistrust

In 2012, the Federal Drug Administration approved daily oral pre-exposure prophylaxis (PrEP) for HIV prevention in adults. Longer acting injectable PrEP (LA PrEP) has been approved and other formulations are in development. A successful LA PrEP rollout requires examining potential facilitators and barriers to PrEP uptake. Given that transgender and gender expansive (TGE) individuals experience more social vulnerability and higher levels of medical mistrust compared to other populations, examining the role of these two factors in LA PrEP uptake is important. This study, PrEP for ALL, is a community-based participatory research project in Texas that engaged TGE community members and organizational partners through a community advisory board. In total, 482 TGE individuals were recruited and responded to all relevant questions in an online survey, including their intentions to use three formulations: a monthly oral pill, a bimonthly intramuscular injection, and an annual subdermal implant. Multiple regression analysis was used to examine the influence of social vulnerability and medical mistrust on intention to use each LA PrEP formulation adjusting for other relevant factors. Findings suggest that individuals with higher levels of social vulnerability had greater intentions to use the monthly oral pill (β = 0.12, p = 0.009), the bimonthly intramuscular injection (β = 0.18, p < 0.001), and annual subdermal implant (β = 0.17, p < 0.001), whereas medical mistrust reduced intentions to use the bimonthly intramuscular injection (β = -0.18, p < 0.001) and annual subdermal implant (β = -0.11, p = 0.021). Improvements in gender-affirming clinical care are needed along with LA PrEP formulations that allow for greater autonomy and reduced clinical contact. Clinical Trial Registration number: NCT05044286.

Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study

Transgender women (TW) face inequities in HIV and unique barriers to PrEP, an effective biomedical intervention to prevent HIV acquisition. To improve PrEP retention among TW, we examined factors related to retention using a two-phase, sequential explanatory mixed methods approach. In Phase I, we used data from a trial of 170 TW who were provided oral PrEP to examine predictors of 24-week retention. In Phase II, we conducted 15 in-depth interviews with PrEP-experienced TW and used thematic analysis to explain Phase I findings. In Phase I, more participants who were not retained at 24 weeks reported sex work engagement (18% versus 7%) and substantial/severe drug use (18% versus 8%). In Phase II, participants reported drug use as a barrier to PrEP, often in the context of sex work, and we identified two subcategories of sex work. TW engaged in "non-survival sex work" had little difficulty staying on PrEP, while those engaged in "survival sex work" struggled to stay on PrEP. In Phase I, fewer participants not retained at 24 weeks reported gender-affirming hormone therapy (GAHT) use (56% versus 71%). In Phase II, participants prioritized medical gender affirmation services over PrEP but also described the bidirectional benefits of accessing GAHT and PrEP. TW who engaged in "survival sex work" experience barriers to PrEP retention (e.g., unstable housing, drug use) and may require additional support to stay in PrEP care.

'I don't want to have to teach every medical provider': barriers to care among non-binary people in the Canadian healthcare system

It is well-known that trans and non-binary individuals experience worse health outcomes due to experiences of violence and discrimination. For this reason, accessible healthcare for trans and non-binary people is crucial. There is a lack of Canadian literature on the experiences of non-binary people within the healthcare system. This study sought to understand barriers to healthcare among non-binary people living in a mid-sized urban/rural region of Canada. Interviews were conducted between November 2019 to March 2020 with 12 non-binary individuals assigned female at birth, living in Waterloo Region, Ontario, Canada, as a part of a larger qualitative study exploring experiences within the community, healthcare and employment. Three broad themes were developed: erasure, barriers to access to healthcare, and assessing whether (or not) to come out. Sub-themes included institutional erasure, informational erasure, general healthcare barriers, medical transition healthcare barriers, anticipated discrimination, and assessing safety. Policy and institutional changes are needed to increase the safety and accessibility of healthcare services to non-binary individuals.

Health Service Utilization and Its Associations with Depression and Sexual Risk Behaviors Among Transgender Women in Shanghai, China

Purpose

Given the limited research on health care utilization among transgender women in China, we described the use of primary health care and gender-affirming health care, and the associations between utilization of gender-affirming health care and depression and sexual risk behaviors.

Methods

We conducted a cross-sectional survey in 2017 among a purposive sample of transgender women in Shanghai, China (N=199). We examined correlates of health care utilization and its association with depression and sexual risk behaviors with Chi-square (χ2), Fisher's exact tests, and analysis of variance.

Results

The majority of the sample (78.5%) only had physician appointments when having an illness, while about one-fifth of the sample had physician appointments for yearly checkups. Nineteen out of 199 participants (9.5%) received gender-affirming surgery, among which only five used hormone therapy prescribed by a doctor (26.3%). Receiving some form of gender-affirming surgery was associated with higher depression scores [Welch's F(2, 12.22)=4.16, p=0.04], engagement in sex work (p=0.001), having 7 or more male sexual partners in the last 30 days (p=0.003), lifetime unprotected sex with a man (p=0.050), and unprotected sex with a main partner (p=0.043). Compared with transgender women who received both breast augmentation and vulvo-vaginoplasty (mean=5.86), those who received breast augmentation only (mean=12.33) scored higher on depression (p=0.04).

Conclusions

Access to gender-affirming health care is low among transgender women in this study. The utilization of gender-affirming surgery is associated with depression and sexual risk behaviors. Findings suggest China should establish national guidelines on transgender-related health care and set up more clinics to provide consultation and services for the transgender population in China.

Assessment of Medical Education on Transgender Health: A Scoping Literature Review

Little is known about how physician learners are assessed following educational interventions about providing gender-affirming care to transgender and gender diverse (TGD) people. The inclusion of learner assessments with educational interventions is essential to understand and measure health professionals' knowledge and skills. We seek to describe how the medical literature has approached the assessment of learners following educational interventions about TGD health. A scoping literature review was done. The guiding research question was "What are the current learner-assessment practices in medical education pedagogy about TGD health?" A total of 270 manuscripts were reviewed. 17 manuscripts were included for data extraction. Miller's pyramid was used to categorize results. 15 used pre- and post-intervention knowledge questionaries to assess learners. Six used simulated patient encounters to assess learners. Most assessments of TGD knowledge and skills among physician learners are pre- and post-surveys. There is sparse literature on higher level assessment following educational interventions that demonstrate learner skills, behaviors, or impact on patient outcomes. Discrete, one-time interventions that are lecture or workshop-based have yet to rigorously assess learners' ability to provide clinical care to TGD patients that is both culturally humble and clinically astute.

A comparison of chronic conditions between transgender and cisgender individuals with recent incarceration and in the community in a United States county

Background: Transgender individuals are known to be at a higher risk for certain chronic conditions compared to cisgender individuals. Similarly, research also shows justice-involved individuals have a higher risk of chronic conditions compared to non-justice-involved individuals. Aim: This study aims to investigate the differences in chronic disease diagnoses between transgender and cisgender individuals who either utilized healthcare services provided by a US county health system or who were incarcerated in the same county's jail. Method: We leveraged electronic health record data from a United States county health system, including data from the local jail, to evaluate the difference in diagnosis of certain chronic conditions among transgender and cisgender individuals. We also compared individuals who experienced incarceration and those who did not. Results: We found transgender individuals experiencing recent incarceration were more likely to be diagnosed with substance use disorder, HIV/AIDS, and Hepatitis C than cisgender individuals. Transgender individuals not experiencing recent incarceration were more likely to be diagnosed with HIV/AIDS, seizure disorder, major depressive disorder, and bipolar disorder than cisgender individuals. Conclusion: These results highlight how transgender individuals may be disproportionately impacted by certain diseases within and outside carceral settings.

Fostering Gender-IQ: Barriers and Enablers to Gender-affirming Behavior Amongst an Australian General Practitioner Cohort

While the visible population of trans and gender diverse Australians has grown significantly in recent years, primary health-care access remains hindered by a lack of practitioner competency and stigmatization. This article draws on qualitative research of purposively selected gender-affirming general practitioners (GPs) in Australia to explore barriers, and enablers when treating trans and gender diverse patients. Perspectives and behaviors during the gender-affirming clinical encounter were theoretically informed through minority stress theory, and master narrative frameworks. Reflexive thematic analysis facilitated a rich description of exemplary gender-affirming primary care. A considerable gap exists between structural, clinical, and cultural behaviors among competent gender-affirming GPs in Australia, and the majority of practitioners evidenced in the literature. This critical analysis contributes to better understanding how gender-affirming Australian GPs diffuse minority stress, negotiate cis-normative biases, and foster a person-centered longitudinal therapeutic relationship with their trans and gender diverse patients. An encounter the article argues may also provide an essential buffer for GPs in Australia against the risk of professional burnout. Gender-affirming practice should be taught as a core competency and be required as professional development for GPs in Australia, to ensure a beneficial clinical encounter for the growing trans and gender diverse population.

The complexities of trans women's access to healthcare in South Africa: moving health systems beyond the gender binary towards gender equity

BACKGROUND

Public health research highlights the influence of socio-political biases shaping obstacles to fair healthcare access based on gender. South Africa has shown commitment to resolving gender imbalances in healthcare, historically emphasizing cisgender women's challenges. However, research gaps exist in exploring how public health systems perpetuate disparities among gender-diverse persons, like trans women, who face exclusion due to their deviation from cisgender norms in healthcare. Critical, intersectionality-informed health research carries the potential to reveal the diversity of gendered healthcare experiences and expose the systems and processes that marginalize trans patients.

METHODS

This study adopts a critical trans politics perspective to explore the socio-political forces limiting South African trans women's access to public healthcare. Using a critical narrative approach, the research asks: 1) What narratives do South African trans women share about their experiences in health systems? 2) What gendered societal structures, practices, and norms enable or hinder their inclusion in health systems? Over a period of two months in 2022, five South African adult trans women between the ages of 22 and 30 participated in 60 to 90-min long, semi-structured individual, telephonic interviews, focusing on participants' subjective experiences in healthcare.

RESULTS

Trans women's narratives unveiled a culture of medical genderism in South African public healthcare, discriminating against patients whose gender misaligns with societal norms. This culture is represented by the trans women's experiences of their identities being structurally stigmatized and delegitimized when seeking healthcare, reflected in institutional policies, practices, and protocols consistently disregarding and misgendering them. Trans women's systemic erasure was illustrated by the restricted professional knowledge, availability, and adoption of gender-affirming healthcare in a ciscentric public healthcare system prioritizing cisgender needs. The intersection of gender, race, and class dynamics compounded the obstacles faced in accessing healthcare.

CONCLUSIONS

This inquiry underscores the structural hurdles trans women face when accessing suitable public healthcare. It introduces a gender equity framework for trans inclusive healthcare, outlining implications for research, theory, policy, and practice. Toward the goal of embracing complexity and diversity, this framework, for example, promotes the rigorous absorption of trans persons and their healthcare experiences in gender-responsive programming, and encourages the development of a comprehensive understanding of gender equity from an intersectional perspective incorporating the unique needs and rights of trans healthcare seekers. The framework also offers practical guidance for cultivating health systems attuned to gender diversity (such as addressing medical genderism and recognizing the broad spectrum of identity at a policy level).

Providing Mindful and Informed Health Care for Patients Who Are LGBTQ+: Perspectives for Clinical Audiology

PURPOSE

More than 7% of the U.S. population identifies as LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other identities), meaning clinical audiologists in all settings are likely to encounter LGBTQ+ patients seeking audiological services. This conceptual clinical focus article (a) introduces contemporary LGBTQ+ terms, definitions, and pertinent issues; (b) summarizes the current state of knowledge on barriers to equitable hearing health care access and utilization for people who identify as LGBTQ+; (c) explores the legal, ethical, and moral obligations for audiologists to provide equitable care to people who identify as LGBTQ+; and (d) provides resources to continue to learn about salient LGBTQ+ issues.

CONCLUSIONS

This clinical focus article provides actionable guidance to clinical audiologists on providing inclusive equitable care to LGBTQ+ patients. Practical actionable guidance on how clinical audiologists can make their clinical practice more inclusive for their patients who identify as LGBTQ+ is provided.

Why do transgender individuals experience discrimination in healthcare and thereby limited access to healthcare? An interview study exploring the perspective of German transgender individuals

BACKGROUND

Transgender individuals experience limited access to healthcare. This results not least from experiences of discrimination to which they are exposed in the health system. These contribute to transgender individuals having poorer health than cis individuals, i.e. individuals whose sex assigned at birth is in line with their gender identity. It is an ethical duty to take effective measures to minimize inequalities in medical care. At best, such measures should also be assessed as appropriate from the perspective of those affected in order to be accepted and thus effective. It is therefore important to know whether measures touch on the subjectively assumed reasons for experiences of discrimination. Hence, to be able to take appropriate measures, it is important to identify the reasons that transgender individuals see as causal for their experiences of discrimination in healthcare.

METHODS

We conducted semi-structured interviews with 14 German transgender individuals and asked them about their own experiences of discrimination in healthcare and their assumptions on the reasons for discrimination. We analyzed the responses using the method of structured qualitative content analysis.

RESULTS

13 transgender individuals reported experiences of discrimination in healthcare. These emanated from different professional groups and took place in trans-specific as well as general medical settings. We were able to identify a total of 12 reasons that transgender individuals see as causal for their experiences of discrimination: (1) internalized trans-hostility and "protection" of cis individuals, (2) lack of knowledge/uncertainties regarding transition, (3) "protection" of a binary worldview, (4) binary worldview in medicine, (5) structural deficits, (6) asymmetric interactions with specialists, (7) current political debate, (8) view of transgender individuals as a "burden for society", (9) objectification, (10) homophobia, (11) misogyny/androcentrism and (12) discrimination as reaction to discrimination.

CONCLUSIONS

German transgender individuals have a very differentiated picture regarding their subjective reasons for experiencing discrimination in healthcare. Overall, disrespect regarding gender identity and a confrontation with foreignness seems to be seen as the decisive factor. Thus, it is not enough to focus only on measures that aim to remedy the information deficit on the part of medical providers. Measures must be taken that can create a granting and respectful attitude towards transgender individuals.

Access to healthcare among sexual and gender minority youth at risk for HIV: barriers and experiences of discrimination

This study examined experiences of healthcare inaccessibility and lesbian, gay, bisexual, transgender, queer, plus (LGBTQ+) discrimination among sexual and gender minority youth at elevated risk for HIV in the United States. Participants for this cross-sectional survey study (N = 3330) were cisgender men, transgender men and women, and nonbinary individuals ages 18-34 recruited for a larger study examining HIV risk behavior between December 2017 and December 2019. Results indicated that 41.1% of participants had at least one lifetime experience of LGBTQ + healthcare discrimination, and 44.1% reported past 6-month experiences of discrimination or problems accessing healthcare. Transgender men and women were more likely than cisgender men and nonbinary participants to report experiences of discrimination, and transgender men were more likely to report problems accessing healthcare. A majority of participants (72.8%) reported that their most recent healthcare provider was aware of their sexual or gender identity. These results indicate a high prevalence of structural barriers in healthcare access for sexual and gender minority youth at elevated risk for HIV, including finical and logistical barriers as well as anticipated and experienced discrimination. We discuss these findings and highlight the importance of easily accessible and culturally competent care for this community.

Assessment of Transgender/Gender-Expansive Accessibility in Inpatient Pediatric Mental Health Facilities

Purpose

This study surveyed a national sample of inpatient pediatric behavioral health facilities on policies related to care for transgender and gender-expansive (TGE) youth to assess adherence to best practices.

Methods

Staff/providers at youth inpatient psychiatric facilities were recruited by phone or email. Participants completed an electronic survey on facilities' training policies, staff comfort related to gender diversity, and other policies related to caring for TGE youth.

Results

Of 479 potential participating facilities, 124 surveys were initiated and 59 were completed. Measures to ensure accessibility to TGE patients are present in many facilities surveyed, with most reporting that their facility had nondiscrimination policies in place (86.2%) and required training on working with TGE patients (52.5%). A minority of participants (12.1%) reported that their facility roomed TGE youth based on sex assigned at birth, although only a small portion roomed based on gender identity alone (19.0%). Slightly more than two-thirds stated that their facility had individual restrooms available. Most participants (74.6%) stated that facility staff were comfortable discussing gender diversity in general, although this was less common for other topics related to TGE patient care.

Conclusion

Our survey highlights efforts made by inpatient behavioral health facilities to ensure accessibility of services to TGE youth, although our results showed notable differences across facilities. Given inconsistent federal protections for TGE patients, there remains a need for efforts to ensure that TGE youth are receiving all possible support in these treatment settings, such as accessible restrooms and bedroom assignments, as well as the opportunity to room with peers.

Increasing a patient's sense of security in the hospital: A theory of trust and nursing action

Having a decreased sense of security leads to unnecessary suffering and distress for patients. Establishing trust is critical for nurses to promote a patient's sense of security, consistent with trauma-informed care. Research regarding nursing action, trust, and sense of security is wide-ranging but fragmented. We used theory synthesis to organize the disparate existing knowledge into a testable middle-range theory encompassing these concepts in hospitals. The resulting model illustrates how individuals are admitted to the hospital with some predisposition to trust or mistrust the healthcare system and/or personnel. Patients encounter circumstances increasing their emotional and/or physical vulnerability to harm, leading to experiences of fear and anxiety. Without intervention, fear and anxiety lead to a decreased sense of security, increased distress, and suffering. Nurse action can ameliorate these effects by increasing a hospitalized person's sense of security or by promoting the development of interpersonal trust, also leading to an increased sense of security. Increased sense of security results in diminished anxiety and fear, and increased hopefulness, confidence, calm, sense of value, and sense of control. The consequences of a decreased sense of security are harmful to patients and nurses should know that they can intervene in ways that both increase interpersonal trust and sense of security.

Societal stigma and mistreatment in healthcare among gender minority people: a cross-sectional study

BACKGROUND

Gender minority (GM; individuals whose gender is not aligned with that traditionally associated with the sex that was assigned to them at birth) people have widely reported mistreatment in healthcare settings. Mistreatment is enacted by individuals within society who hold stigmatizing beliefs. However, the relationship between healthcare mistreatment and societal stigma (i.e., the degree to which society disapproves of GM people) is unclear and not measured consistently.

METHODS

We analyzed data from 2,031 GM participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study's 2019 Annual Questionnaire to determine whether societal stigma was associated with participants' past-year reports of mistreatment (defined as denial of healthcare services and/or lower quality care) in medical or mental healthcare settings. We created a proxy measure of societal stigma by incorporating variables validated in existing literature. Participants reported whether they had experienced mistreatment in medical and mental health settings independently.

RESULTS

Healthcare denial and/or lower quality care during the past year was reported by 18.8% of our sample for medical settings and 12.5% for mental health settings. We found no associations between the societal stigma variables and past-year reports of healthcare denial and/or lower quality care in medical or mental healthcare settings.

CONCLUSIONS

Although a high proportion of GM people reported past-year healthcare mistreatment in both medical and mental health settings, mistreatment had no relationship with societal stigma. Factors other than societal stigma may be more important predictors of healthcare mistreatment, such as healthcare workers' knowledge of and attitudes toward GM people. However, other measures of societal stigma, or different types of mistreatment, may show stronger associations. Identifying key factors that contribute to mistreatment can serve as targets for intervention in communities and healthcare settings.

Voices from a Multidisciplinary Healthcare Center: Understanding Barriers in Gender-Affirming Care-A Qualitative Exploration

When seeking gender-affirming care, trans* and gender-diverse individuals often describe experiencing barriers. However, a deeper understanding of what constitutes such barriers is generally lacking. The present research sought to better understand the barriers trans* and gender-diverse individuals experienced, and their effects, when seeking gender-affirming care in the Netherlands. Qualitative interviews were conducted with trans* and gender-diverse individuals who sought care at a Dutch multidisciplinary medical center. Twenty-one participants were included, of which 12 identified as (trans) male, six identified as (trans) female, one as trans*, and one as gender-nonconforming (GNC)/non-binary. The interviews were mostly conducted at the homes of the participants and lasted between 55 min and 156 min (mean = 85 min). Following data collection and transcription, the interviews were analyzed using axial coding and thematic analysis. A total of 1361 codes were extracted, which could be classified into four themes describing barriers: lack of continuity: organizational and institutional factors (n_codes = 546), patient-staff dynamics (n_codes = 480), inadequate information and support (n_codes = 210), and lack of autonomy in decision making (n_codes = 125). Within our study, trans* and gender-diverse individuals described encountering multiple and diverse barriers when seeking gender-affirming care in the Netherlands. Future studies are needed to evaluate whether individualized care, the decentralization of care, and the use of decision aids can improve the experienced barriers of trans* and gender-diverse individuals seeking gender-affirming care within the Dutch healthcare system.

Transgender Women's Experiences Using SMARTtest, a Smartphone Application to Facilitate Self- and Partner-HIV/Syphilis Testing Using the INSTI Multiplex

We present experiences of transgender women (TW) who have sex with men with SMARTtest, a smartphone app to accompany the INSTI Multiplex®, a one-minute, dual blood-based HIV/syphilis rapid test. TW participants (N = 11) received 10 INSTI Multiplex® tests to take home for self- and/or partner-testing and installed the SMARTtest app on their phones. The SMARTtest app aimed to support INSTI Multiplex users in correctly performing the test, interpreting the results, and connecting with care following a positive HIV or syphilis screening. After 3 months, users completed in-depth interviews on their experiences. A total of  9 TW used SMARTtest with partners. App feedback was positive, but refining is necessary. Specifically, TW reported that SMARTtest is easy to use and convenient; instructions on how to use the INSTI Multiplex presented on the app were helpful to complete procedures correctly; the most frequently used feature on SMARTtest was the information on clinics that offered confirmatory testing; and participants and their partners were not concerned about app privacy but reported that this could change if INSTI Multiplex detected an HIV-positive result. Further, participants provided recommendations on how to improve SMARTtest, and changes were mostly related to features, content, functionality, navigation, and overall "look" of the app. SMARTtest is promising to facilitate INSTI Multiplex® use in TW. User feedback should be integrated in future versions.

Models of Gender Dysphoria Using Social Media Data for Use in Technology-Delivered Interventions: Machine Learning and Natural Language Processing Validation Study

BACKGROUND

The optimal treatment for gender dysphoria is medical intervention, but many transgender and nonbinary people face significant treatment barriers when seeking help for gender dysphoria. When untreated, gender dysphoria is associated with depression, anxiety, suicidality, and substance misuse. Technology-delivered interventions for transgender and nonbinary people can be used discretely, safely, and flexibly, thereby reducing treatment barriers and increasing access to psychological interventions to manage distress that accompanies gender dysphoria. Technology-delivered interventions are beginning to incorporate machine learning (ML) and natural language processing (NLP) to automate intervention components and tailor intervention content. A critical step in using ML and NLP in technology-delivered interventions is demonstrating how accurately these methods model clinical constructs.

OBJECTIVE

This study aimed to determine the preliminary effectiveness of modeling gender dysphoria with ML and NLP, using transgender and nonbinary people's social media data.

METHODS

Overall, 6 ML models and 949 NLP-generated independent variables were used to model gender dysphoria from the text data of 1573 Reddit (Reddit Inc) posts created on transgender- and nonbinary-specific web-based forums. After developing a codebook grounded in clinical science, a research team of clinicians and students experienced in working with transgender and nonbinary clients used qualitative content analysis to determine whether gender dysphoria was present in each Reddit post (ie, the dependent variable). NLP (eg, n-grams, Linguistic Inquiry and Word Count, word embedding, sentiment, and transfer learning) was used to transform the linguistic content of each post into predictors for ML algorithms. A k-fold cross-validation was performed. Hyperparameters were tuned with random search. Feature selection was performed to demonstrate the relative importance of each NLP-generated independent variable in predicting gender dysphoria. Misclassified posts were analyzed to improve future modeling of gender dysphoria.

RESULTS

Results indicated that a supervised ML algorithm (ie, optimized extreme gradient boosting [XGBoost]) modeled gender dysphoria with a high degree of accuracy (0.84), precision (0.83), and speed (1.23 seconds). Of the NLP-generated independent variables, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) clinical keywords (eg, dysphoria and disorder) were most predictive of gender dysphoria. Misclassifications of gender dysphoria were common in posts that expressed uncertainty, featured a stressful experience unrelated to gender dysphoria, were incorrectly coded, expressed insufficient linguistic markers of gender dysphoria, described past experiences of gender dysphoria, showed evidence of identity exploration, expressed aspects of human sexuality unrelated to gender dysphoria, described socially based gender dysphoria, expressed strong affective or cognitive reactions unrelated to gender dysphoria, or discussed body image.

CONCLUSIONS

Findings suggest that ML- and NLP-based models of gender dysphoria have significant potential to be integrated into technology-delivered interventions. The results contribute to the growing evidence on the importance of incorporating ML and NLP designs in clinical science, especially when studying marginalized populations.

Investigating discrimination in the workplace. Translation and validation of the Everyday Discrimination Scale for nursing staff in Germany

BACKGROUND

The Everyday Discrimination Scale (EDS) is a frequently used questionnaire in the field of health and social psychology that aims to explore perceptions of discrimination, especially instances of injustice related to various diversity characteristics. No adaptation to health care staff exists. The present study translates and adapts the EDS to nursing staff in Germany and examines its reliability and factorial validity as well as its measurement equivalence between men and women and different age groups.

METHODS

The study was based on an online survey conducted among health care staff of two hospitals and two inpatient care facilities in Germany. The EDS was translated using a forward-backward translation approach. Direct maximum likelihood confirmatory factor analysis (CFA) was conducted to examine the factorial validity of the adapted EDS. Differential item functioning (DIF) related to age and sex was investigated by means of multiple indicators, multiple causes (MIMIC) models.

RESULTS

Data on 302 individuals was available, of whom 237 (78.5%) were women. The most commonly employed one-factor, 8-item baseline model of the adapted EDS showed a poor fit (RMSEA = 0.149; CFI = 0.812; TLI = 0.737; SRMR = 0.072). The model fit improved considerably after including three error covariances between items 1 and 2, items 4 and 5, and items 7 and 8 (RMSEA = 0.066; CFI = 0.969; TLI = 0.949; SRMR = 0.036). Item 4 showed DIF related to sex and age, item 6 showed DIF related to age. DIF was moderate in size and did not bias the comparison between men and women or between younger and older employees.

CONCLUSIONS

The EDS can be considered a valid instrument for the assessment of discrimination experiences among nursing staff. Given that the questionnaire, similar to other EDS adaptations, may be prone to DIF and also considering that some error covariances need to be parameterized, latent variable modelling should be used for the analysis of the questionnaire.

Improving healthcare quality for transgender patients in the perioperative setting: The patient's perspective

Transgender individuals reported higher rates of discrimination and barriers to care within healthcare settings than their cisgender counterparts. There is a paucity of literature concerning the barriers experienced within perioperative healthcare settings. Participants completed a sociodemographic questionnaire and a 7-item Likert-type scale survey: the Everyday Discrimination Scale Adapted for Medical Settings. Overall, 57% of trans-individuals who underwent gender-affirming surgery reported perceptions of discrimination when interacting with healthcare providers within the perioperative setting according to responses from the Discrimination in Medical Settings Survey. There was an overall difference in the summary scores between participants based on gender transition. These findings highlight an opportunity to address barriers to care related to discrimination and negative patient-provider interactions. These findings have implications for the development and integration of patient-informed, evidence-based, trans-specific, educational and cultural competency trainings to enhance the healthcare professional's knowledge, attitudes, comfort and ability to care for the transgender population.Key phrases: Transgender individuals reported higher rates of discrimination and barriers to care; enhancing the healthcare professional's knowledge, attitudes, comfort and ability to care for the transgender population; opportunities to address barriers to care related to discrimination and negative patient-provider interactions; individuals who transitioned from male-to-female (MTF) had higher scores related to perceptions of discrimination during interactions with healthcare providers.

Using laws, common sense, and statistical approaches to design indicators for 'medical desertification'. An application on the Romanian case

The study of spatial accessibility to healthcare services is key to health policy (Pförtner et al., 2019; Vergier et al., 2017). Terms such as 'rurality' or 'medical desertification' were employed to stress the relevance of the topic. Within the existing literature, there is little (if any) concern with the legitimacy of the existing ways to measure inequality. Expert systems were assumed to be in place, and discrepancies or consistency with existing regulations or to views of relevant stakeholders were not considered. This paper discusses spatial accessibility of medical services in three distinct approaches: normative, that is following what national regulations consider as standard; relative, that is what statistical approaches reveal; consensual, which adjusts the indexes based on representations of stakeholders. The three approaches are compared for the case of Romania, an EU country with low population density, ideal to inspect geographical discrepancies. For the relative and the consensual approach, population is adjusted according to different demand expressed by age groups, and also including population and providers from the nearby localities. The normative approach follows official regulations. The refinements in the consensual model are based on survey data from stakeholders and consider distances to neighbouring localities and adjustments according to the age structure of the population in the catchment area. The results reveal high consistency between the consensual and the relative approach. Both are more permissive with respect to detecting medical desertification as compared to the normative approach but prove to be more effective in directing policy when resources are scarce. The normative approach, however, is relevant in depicting the state of the system as contrasted to a desired standard. The relative approach also overlaps with the consensual one. Therefore, to fully characterize spatial accessibility to general practitioners (GPs) and pharmacies, one needs to consider at least the normative and the relative approaches.

Stressors in health care and their association to symptoms experienced by gender diverse people

OBJECTIVES

Many individuals whose gender does not align with the sex they were assigned at birth (gender diverse [GD] people) report stressful health care encounters. We examined the relationship of these stressors to symptoms of emotional distress and impaired physical functioning among GD people.

STUDY DESIGN

This study was conducted using a cross-sectional design with data from the 2015 United States Transgender Survey.

METHODS

Composite metrics of health care stressors and physical impairments were developed, and the Kessler Psychological Distress Scale (K-6) provided a measure of emotional distress. Linear and logistic regression were used to analyze the aims.

RESULTS

A total of 22,705 participants from diverse gender identity subgroups were included. Participants who experienced at least one stressor in health care during the past 12 months had more symptoms of emotional distress (β = 0.14, P < .001) and 85% greater odds of having a physical impairment (odds ratio = 1.85, P < .001). Transgender men exposed to stressors were more likely than transgender women to experience emotional distress and have a physical impairment, with other gender identity subgroups reporting less distress. Black participants exposed to stressful encounters reported more symptoms of emotional distress than White participants.

CONCLUSIONS

The results suggest that stressful encounters in health care are associated with symptoms of emotional distress and greater odds of physical impairment for GD people, with transgender men and Black individuals being at greatest risk of emotional distress. The findings indicate the need for assessment of factors that contribute to discriminatory or biased health care for GD people, education of health care workers, and support for GD people to reduce their risk of stressor-related symptoms.

Hyper-invisibility and visual scrutiny: reflections from photo-narrative research with transgender young persons

In recent years, photo-narrative methods have gained popularity as a feminist decolonial research approach. Located within the broader category of participatory action research, photovoice is committed to the democratisation of the research process. It aims to centre previously excluded knowledges and problematises what is considered ‘legitimate’ ways of knowing within the social sciences. As such, photovoice has been utilised across a wide range of studies that are aligned with a social justice agenda. Arising are questions around the burden of representation that is placed on participants; what it means for stories of marginalisation to be put ‘on display’; and the risk involved in disclosing personal experiences when there is a power differential between storyteller and audience. By highlighting complications encountered when conducting a photo-narrative project with transgender young persons in Cape Town, South Africa, this methodologically reflexive paper contributes to this conversation. We explore the nuances and complexities that arose when using a methodology that relies heavily on visual data, on a community that experiences intense visual scrutiny daily. As a result, the research focused on participants’ narratives of invisibility and hypervisibility as presented in the data, thus bringing a reflexive stance and interrogation to assumptions of the approach often taken for granted.

Mapping transgender policies in the US 2017-2021: The role of geography and implications for health equity

Transgender individuals globally face varying policy contexts that can influence their health. In the United States (US), a patchwork of exclusionary and inclusive policies exists, creating potentially different social and political contexts that shape transgender health depending on the state. In this article, we consider how recent legislation introduced in US states focused on transgender people may be a political determinant of health and affect health equity goals. To advance this aim, we employed the perspective of legal epidemiology to systematically search a US legal database (Westlaw) for policies focused on transgender individuals proposed between January of 2017 and September of 2021.698 policies were analyzed as affirming or exclusionary of transgender identities and categorized by content. We calculated a ratio of affirming versus exclusionary bills to create "exclusionary density" and "affirming density" measures. Those measures were used to calculate an inclusivity score and corresponding maps of inclusivity and exclusionary contexts by US state. Exclusionary and affirming density measures showed deeply polarized policy responses to transgender individuals depending on US state. Further, we observed differences in magnitude regarding the laws being proposed. Exclusionary laws largely focused on criminalization while inclusionary laws focused on representation in government agencies. These findings highlight that transgender individuals in the US can experience vastly different political contexts depending on where they live.

The Dobbs Decision and the Future of Occupational Health in the US

Access to abortion care has a profound impact on women's ability to participate in the workforce. In the US, restrictions on abortion care have waxed and waned over the years, including periods when abortion was broadly permitted across the nation for most pregnant people for a substantial proportion of pregnancy and times when restrictions varied across states, including states where abortion is banned for nearly all reasons. Additionally, access to abortion care has always been a reproductive justice issue, with some people more able to access this care than others even when it is structurally available. In June 2022, the US Supreme Court handed down the Dobbs v. Jackson Women's Health Organization, returning to states the ability to determine restrictions on abortion, including near-total bans on abortion. In this anthology, ten experts share their perspectives on what the Dobbs decision means for the future, how it will exacerbate existing, well-researched issues, and likely also create new challenges needing investigation. Some contributions are focused on research directions, some focus on implications for organizations, and most include both. All contributions share relevant occupational health literature and describe the effects of the Dobbs decision in context.

Experiences of parents of trans young people accessing Australian health services for their child: Findings from Trans Pathways

Background

Many trans young people seek mental health support and gender-affirming medical interventions including puberty suppression, gender-affirming hormones and/or surgeries. Trans young people and their parents face multiple barriers in accessing gender-affirming care and mental health support, however little is known about the parent perspective on accessing services for their trans child.

Aims

This study aimed to understand the experiences of parents accessing medical and mental health services with and for their trans children within Australia.

Methods

Using data from Trans Pathways, a large mixed-methods cross-sectional study, we examined the experiences of parents (N = 194) in Australia accessing primary care, psychiatry, therapy/counseling, mental health inpatient, and gender-affirming medical services with/for their trans children (aged 25 years or younger). Qualitative data on service experiences were thematically analyzed. Quantitative analyses included frequency of access to services, wait times, service satisfaction, and mental health diagnoses of the parents' trans child.

Results

Services were mostly first accessed when the young person was between 12 and 17 years of age, with primary care physicians being the most accessed service. Parents reported that some practitioners were respectful and knowledgeable about gender-affirming care, and others lacked experience in trans health. Across all services, common barriers included long wait times, complicated pathways to navigate to access support, as well as systemic barriers such as sparsity of gender speciality services. Across services, parents reported feeling as though they do not have the necessary tools to best support their child in their gender affirmation.

Discussion

This study highlights the crucial need for systemic changes in the processes of accessing gender-affirming care and mental health support to enable access to appropriate and timely care. These findings also indicate the importance of improving individual practitioner knowledge around trans health, to enhance the support provided to trans young people and their parents.

Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study

BACKGROUND

Although discriminatory experiences of transgender people seeking healthcare services have been well-documented in several studies, differentiating those experiences based on gender identity/expression and related factors has been limited. The aim of this study was to compare the characteristics, experiences, attitude, and expectation toward accessing healthcare service and healthcare providers of transgender women and transgender men in Thailand.

METHODS

A cross-sectional study was conducted from October 2017 to March 2018. The data were collected from transgender women and transgender men aged ≥ 18 years old who lived in Thailand using online platform via different websites and Facebook pages of local transgender group. Binary logistic regression was used to identify the factors related to the study outcomes.

RESULTS

Of 186 transgender people who responded to the questionnaire and were eligible for the study, 73.7% (95% confidence interval [CI] = 66.7-79.8) were transgender women and 26.3% (95% CI = 20.2-33.3) were transgender men. Transgender women were more likely to seek general healthcare from non-traditional healthcare services (crude odds ratio [cOR] = 4.28; 95% CI = 1.55-11.81; P = 0.005), buy hormone treatment from non-traditional healthcare services (cOR = 3.89; 95% CI = 1.18-12.83; P = 0.026), and receive healthcare counseling from non-traditional healthcare providers (cOR = 5.16; 95% CI = 1.42-18.75; P = 0.013) than transgender men. According to the results of applying a multivariable model, transgender respondents who did not know that gender-affirming healthcare services existed in Thailand were more unwilling to receive counseling from gender-affirming healthcare providers than those who did (adjusted odds ratio = 3.70; 95% CI = 1.11-12.36; P = 0.033).

CONCLUSIONS

The findings from this cross-sectional study indicate that transgender women are more likely than transgender men to receive general healthcare and hormone treatment from non-traditional healthcare services and buy hormone treatment without a physician's supervision. We also found approximately 15% of transgender individuals who did not receive gender-affirming counseling services. Continuing to improve access to care for the transgender community, increasing public relations channels may encourage transgender people to access more healthcare services.

Caring for Transgender People in Healthcare: A Qualitative Study with Hospital Staff in Croatia

Transgender and gender-diverse people have greater health risks due to increased social stress and face a disadvantaged position in the healthcare system as a result of the stigma associated with their gender identity. Due to the lack of research in Croatia on the position of transgender people in the healthcare system, this research was intended to supplement the knowledge about the experiences of hospital staff in the Croatian healthcare system when caring for patients with transgender identities. Qualitative research was conducted using an interview method. The participants (n = 10) were healthcare managers or hospital care team members. The collected data were processed through thematic analysis. The results show that some participants had had no encounters with transgender patients and those who had described them as unproblematic or had only encountered them at a level of basic healthcare. They also described how they perceive transgender people and their life circumstances. The participants described how they envision potential encounters with this group of patients and what they consider necessary to improve the position of this group within the healthcare system. In the discussion part of the article, we assess the need for additional training regarding hospital staff, especially in terms of diversity competence, and for an increase in the visibility of transgender patients.

Correlates of HIV Testing across the lifespan - adolescence through later adulthood - among sexual minority men in the US who are not on PrEP

Regular HIV testing is an essential component of the HIV prevention and care cascade. Sexual minority males (SMM) account for most new HIV infections in the US and testing rates among SMM vary substantially across the lifespan. Research has largely overlooked the developmental context of HIV testing. The current study compared correlates of HIV testing among adolescents (aged 13-17; n = 1,641), emerging adults (aged 18-29; n = 50,483), early adults (aged 30-39; n = 25,830), middle adults (aged 40-64; n = 25,326), and late adults (65 and older; n = 1,452) who were recruited online. Overall, HIV testing rates were lowest among adolescent SMM. Having condomless anal sex in the past 3-months was a consistentpredictor of HIV testing across all age cohorts.The association between relationship status and frequency of HIV testing varied across ages. Being in a non-monogamous relationship (versus single) was associated with more frequent HIV testing among adolescent and emerging adult SMM , while being in a monogamous relationship (versus single) was associated with lower odds of HIV testing among early, middle, and late adults.

Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area

BACKGROUND

Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited.

METHODS

We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data.

RESULTS

Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use.

CONCLUSIONS

Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

Binary and Nonbinary Transgender Adolescents' Healthcare Experiences, Avoidance, and Well Visits

PURPOSE

To explore differences in healthcare experiences, healthcare avoidance, and well visit attendance between binary and nonbinary transgender adolescents; also, to explore the association between distinct healthcare experiences and healthcare avoidance and well visits.

METHODS

We surveyed transgender adolescents ages 12-26 (n = 156) recruited from a multidisciplinary gender clinic from July through November 2018. Differences in distinct healthcare experiences by demographics were assessed using multivariable linear regression. Multivariable logistic regression was used to examine independent associations between demographics and lifetime healthcare avoidance and past-year well visit and also, associations between distinct healthcare experiences and lifetime healthcare avoidance and past-year well visit.

RESULTS

Compared to transfeminine adolescents, more non-affirming healthcare experiences were reported by nonbinary (β = 1.41, 95% confidence interval [CI]: 0.49, 2.33) and transmasculine adolescents (β = 0.78, 95% CI: 0.02, 1.53). Gender-affirming healthcare experiences did not differ by demographics. Transmasculine adolescents had over three times the odds of lifetime healthcare avoidance (adjusted odds ratio [aOR] = 3.58, 95% CI: 1.41, 9.08) than transfeminine peers. Only younger age was associated with past-year well visit (aOR = 3.83, 95% CI: 1.44, 10.17). Non-affirming healthcare experiences were positively associated with healthcare avoidance (aOR = 1.85, 95% CI: 1.47, 2.34). Gender-affirming healthcare experiences were not associated with healthcare avoidance or past-year well visit.

DISCUSSION

Nonbinary and transmasculine adolescents experienced more non-affirming healthcare experiences than transfeminine adolescents. Non-affirming healthcare experiences were associated with healthcare avoidance, which was disproportionately more prevalent among transmasculine adolescents. Providers must be better equipped to provide inclusive, gender-affirming care to increase receipt of care for transgender adolescents beyond specialized gender clinics.

TRANSALUD: A qualitative study of the healthcare experiences of transgender people in Barcelona (Spain)

Transgender identities are still considered a psychiatric pathology in many countries according to the prevailing biomedical model. However, in recent years, this pathologizing vision has begun to shift towards a perspective that focuses on the diversity of transgender peoples’ experiences. However, some transgender people still face denial of services, discrimination, harassment, and even violence by healthcare professionals, causing them to avoid seeking ongoing or preventive healthcare. This article describes the health experiences of transgender people in Barcelona regarding their access and use of non-specialized health services. Semi-structured interviews were conducted using a descriptive phenomenological approach with sixteen transgender people between December 2018 and July 2019. The data were analyzed descriptively and thematically following the method proposed by Colaizzi with the help of the Atlas.ti8 software. Transgender people care experiences were divided into three categories: overcoming obstacles, training queries, and coping strategies. Participants identified negative experiences and difficulties with the health system due to healthcare providers’ lack of competence. Discriminatory, authoritarian, and paternalist behaviors are still present and hinder the therapeutic relationship, care, and access to healthcare services. There is a fundamental need for the depathologization of transgender reality and training for healthcare professionals in the field of sexual diversity. Training in sexual and gender diversity must be included in the curricula of university courses in the health sciences.

Exploring the microaggression experiences of LGBTQ+ community for a culturally safe care: A descriptive qualitative study

BACKGROUND

Microaggressions, stigma and minority stress still occur among sexual and gender minorities on an individual, interpersonal, and structural level. Cultural immersion may therefore be an effective strategy in order to find potential healthcare approaches and foster more comprehensive, critical, intersectional, and inclusive care practices.

OBJECTIVE

The aim of this study was to develop insight into the experiences of LGBTQ+ community members to obtain in-depth perceptions of microaggressions and an understanding of their healthcare needs to provide a culturally safe and sensitive care.

DESIGN

A qualitative descriptive study was conducted between September to November 2021.

SETTINGS

This study was conducted at the University of Almeria with LGBTQ+ community members.

PARTICIPANTS

Twenty-one LGBTQ+ individual participated in this study, aged between 18 and 56 years old.

METHODS

Participants were recruited using a purposive sampling. Responses from semi-structured interviews were studied using a thematic analysis. Methods and findings are reported in line with Standards for Reporting Qualitative Research recommendations.

RESULTS

Three themes emerged from the qualitative analysis: (i) experiences to understand the impact of a heteronormative society, (ii) perceptions of engaging with health education and promotion, and (iii) healthcare access, use and experiences within the LGTBQ+ community.

CONCLUSIONS

This study yields findings about the difficulties that LGBTQ+ community members face in the healthcare system in order to ensure equal care for vulnerable communities and integrate a culturally safe care approach into nursing practice. Certain microaffirmation strategies against social determinants of health such as school-based nursing strategies can help to raise awareness and knowledge among heterosexual peers and reduce cultural invisibility, microaggressions, stigma and minority stress. In order to provide culturally safe care, educators might also explore the inclusion of gender and sexual minority care content in both in-faculty education and ongoing continuing education for nurse practitioners.

"Truly Listen to Us": Recommendations for Health Professionals to Bolster Wellbeing of Nonbinary Individuals

Trans-affirming providers play significant roles in the health and wellbeing of nonbinary individuals. Yet, healthcare mistreatment is well-documented among gender-diverse patients, leading to clients withholding information and avoiding care for fear of experiencing bias. Concurrently, healthcare providers report feeling ill-equipped to serve nonbinary patients, often perpetuating cisnormative binary attitudes. The literature has established the challenges to accessing healthcare and the need for gender-affirming care. However, little is known about nonbinary people’s perspectives on how best to deliver gender-affirming care that is inclusive of nonbinary patients. This participatory action PhotoVoice study identified community member recommendations for healthcare providers to bolster the wellbeing of nonbinary individuals through improved access to gender-affirming healthcare. Data were collected through group discussions, photography, and photo-elicitation interviews. Drawing upon research results, the authors identify recommendations for improving interpersonal care, increasing access to gender-affirming care, and advocating for related environmental and policy changes.

Barriers to accessing and engaging in healthcare as potential modifiers in the association between polyvictimization and mental health among Black transgender women

BACKGROUND

Black transgender women endure pervasive polyvictimization (experiencing multiple forms of violence throughout the lifespan). Polyvictimization is associated with poor mental health. Black transgender women also face barriers in access to healthcare, but the extent that such barriers modify the association between polyvictimization and poor mental health has not been described using convergent mixed-methods analysis.

METHODS

This convergent mixed-methods secondary analysis employs an intersectional lens and integrates two inter-related datasets to describe barriers to healthcare and the extent that such barriers modify the association between polyvictimization and mental health among Black transgender women. Investigators used survey data (n = 151 participants) and qualitative interview data (n = 19 participants) collected from Black transgender women (age 18 years and older) in Baltimore, MD and Washington, DC between 2016 and 2018. Analyses include thematic content analysis, bivariate analysis, joint display, and multivariate linear regression analysis examining mediation and moderation.

RESULTS

Joint display illuminated three domains to describe how barriers to healthcare present among Black transgender women-Affordability, Accessibility, and Rapport and Continuity. Independent t-tests revealed significantly higher polyvictimization, Post Traumatic Stress Disorder (PTSD), and depression scores among participants who reported at least one barrier to healthcare (BHI) compared to those who reported no barriers. BHI significantly moderated and partially mediated the association between polyvictimization and PTSD symptom severity and BHI fully mediated the association between polyvictimization and depressive symptom severity-when accounting for age and location.

DISCUSSION

Findings highlight the importance of access to healthcare in modifying the association between polyvictimization and PTSD and depression symptom severity among Black transgender women. Findings call for immediate interventions aimed at reducing barriers to healthcare and improved training for clinical providers serving Black transgender women.

Surgical Treatment of Granulomatous Breast Deformities Caused by Injection of Foreign Substances in Transgender Women: A Case Series and Algorithm

SUMMARY

Despite potentially devastating complications, free foreign substance injections for feminizing breast augmentation remain common among transgender women. To date, the literature regarding surgical treatment of these deformities among transgender women remains limited. The authors present a case series of transgender women presenting for surgical management of granulomatous breast deformities secondary to free foreign substance injections between January of 2016 and February of 2020. Seven transgender women presented for surgical management of complications secondary to free foreign substance injections of the breast. These patients ranged in age from 29 to 53 years, all identified as Hispanic/Latinx, and five were primarily Spanish speakers. All were recipients of public insurance. Six of the seven patients received free foreign substance injections outside of the United States, with an average time from initial injections to presentation of 19.3 ± 15.7 years. Three patients presented with a history of prior revisions by other surgeons. Four underwent staged reconstruction at the authors' institutions. Patients were followed for, on average, 10.7 ± 12.6 months after their initial surgery. There were no major complications. The most common minor complication was delayed wound healing. In the present series, the authors illustrate that, with careful consideration and patient selection, it is possible to perform safe and successful breast reconstruction for the management of foreign substance granulomas in transgender women. They also provide an algorithm based on patient-specific factors to guide treatment decisions in this patient population. Further research is needed to determine the generalizability and applicability of this algorithm.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Diversity-sensitive measures in German hospitals - attitudes, implementation, and barriers according to administration managers

Background

Populations have varying needs and expectations concerning health care that result from diversity characteristics such as a migrant background, gender identity, disability, and age. These needs and expectations must be considered to ensure adequate utilization and quality of health services. Approaches to address diversity do exist, however, little is known about the extent to which they are implemented by health care facilities. The present study aims to examine, which measures and structures hospitals in Germany employ to address diversity, as well as which barriers they encounter in doing so.

Methods

A mixed-mode survey among administration managers of all registered German hospitals (excluding rehabilitation hospitals; n = 1125) was conducted between May and October 2019 using pen-and-paper and online questionnaires. Results were analyzed descriptively.

Results

Data from n = 112 hospitals were available. While 57.1% of hospitals addressed diversity in their mission statement and 59.9% included diversity considerations in quality management, dedicated working groups and diversity commissioners were less prevalent (15.2% each). The majority of hospitals offered multi-lingual admission and exit interviews (59.8%), treatments or therapies (57.1%), but only few had multi-lingual meal plans (12.5%) and seminars or presentations (11.6%). While 41.1% of the hospitals offered treatment and/or nursing exclusively by staff of the same sex, only 17.0% offered group therapies for both sexes separately. According to the managers, the main barriers were a lack of financial resources (54.5%), a lack of incentives from the funding providers (49.1%), and organizational difficulties (45.5%). Other reported barriers were a lack of conviction of the necessity among decision makers (28.6%) and a lack of motivation among staff members (19.6%).

Conclusions

Administration managers from only a small proportion of hospitals participated in our survey on diversity sensitivity. Even hospitals of those who did are currently not adequately addressing the diversity of staff members and patients. Most hospitals address diversity on an ideational level, practical measures are not widely implemented. Existing measures suggest that most hospitals have no overarching concept to address diversity in a broader sense. The main reported barriers relate to economic aspects, a lack of support in organizing and implementing corresponding measures and a lack of awareness or motivation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08058-3.

To Go or Not to Go: Factors That Influence Health Care Use Among Trans Adults in a Non-Representative U.S. Sample

Trans people tend to utilize health care at rates lower than cisgender people, which commonly results in short-term and long-term unfavorable health outcomes. Theoretically informed by Andersen's behavioral model of health services use and Lerner and Robles' adapted behavioral model of health services use for transgender people, the current study examined how individual characteristics of trans people along with the external environment and health care service environment they must navigate impact their health care utilization. Binary logistic regression was used to analyze data from the 2015 United States Trans Survey (N = 27,715), the largest trans sample to date. Perception of health care provider (HCP) knowledge, health insurance status, and health care costs each produced the strongest effect on visiting a doctor or HCP in the past year. The results showed that having a provider that had some level of knowledge about trans people was potentially most critical to increase utilization. Discussion points include increasing trans-focused curriculum in health professional schools, utilizing trans standardized patients in health professional schools, and holding insurance companies accountable to provide trans affirming care.

Explicit and Implicit Gender-Related Stereotyping in Transgender, Gender Expansive, and Cisgender Adults

Little is known about gender-related stereotyping among transgender and gender expansive adults. Using the Ambivalent Sexism Inventory (AIS; Glick & Fiske, 1996), we examined explicit gender attitudes in 3298 cisgender, transgender, and gender expansive respondents designated female at birth (FAB; n = 1976 cisgender, n = 108 transgender, n = 188 gender expansive) and male at birth (MAB; n = 922 cisgender, n = 52 transgender, n = 52 gender expansive). In order to learn more about implicit gender-related stereotyping, a subset of 822 participants (FAB; n = 445 cisgender, n = 32 transgender, n = 51 gender expansive. MAB; n = 254 cisgender, n = 21 transgender, n = 19 gender expansive) completed the gender-leadership Implicit Association Test (IAT; Dasgupta & Asgari, 2004). Cisgender men scored significantly higher than all other groups on hostile sexism, but patterns of endorsement for benevolent sexism and implicit attitudes were more nuanced, with cisgender women and gender expansive FAB often scoring significantly below other groups. We observed that transgender men and transgender women, along with cisgender men and gender expansive MAB, moderately endorsed essentialist views regarding differences between men and women (i.e., complementary gender differentiation). These data reveal novel patterns of gender-related stereotyping, with some corresponding to sex designated at birth and others corresponding to current gender identification. Together, these findings suggest that one's experienced gender, designated sex at birth, and the intersection between them may relate to gender stereotyping, underscoring the importance of including transgender and gender expansive individuals in this research.

A Content Analysis of Osteopaths’ Attitudes for a More Inclusive Clinical Practice towards Transgender People

Objectives. The aim of this qualitative study was to explore the attitudes, beliefs, and preferences of Italian osteopaths regarding the management of transgender patients through a content analysis of emergent data from semi-structured interviews. Methods. This study was a content analysis based on the Standards for Reporting Qualitative Research guidelines. Purposive sampling of 10 Italian osteopaths was applied. Data were collected through semi-structured interviews, from March to April 2021, and subsequently transcribed verbatim with the content analysis carried out as an iterative process. Results. One participant was excluded during the first interview due to them being unsuitable for this study. Data saturation was reached after two interviews with the remaining nine participants. Data analysis revealed four main themes: microaggressions, acceptance and non-judgement, person-centered treatment, and education implementation. Conclusions. This study presents cisgender Italian osteopaths’ attitudes in the care of transgender people, revealing the desire to embrace and apply osteopathic tenets regardless of the patient’s gender identity.

“We Are Doing the Absolute Most That We Can, and No One Is Listening”: Barriers and Facilitators to Health Literacy within Transgender and Nonbinary Communities

Transgender and nonbinary (TNB) individuals face disparities in nearly every aspect of health. One factor associated with poor health outcomes in other marginalized populations is health literacy, yet no identified studies examine health literacy in TNB samples. Moreover, most health literacy frameworks focus primarily on the capacities of individual patients to understand and use healthcare information, with little attention given to provider literacy and environmental factors. In partnership with a statewide LGBTQ advocacy organization, we recruited 46 transgender and nonbinary individuals to participate in seven focus groups conducted in urban, suburban, and rural locations throughout Colorado. TNB participants consistently engaged in efforts to increase their own health literacy and that of their medical providers yet faced multiple barriers to improve care. Difficulty identifying and physically reaching care, insurance and out-of-pocket expenses, negative experiences with healthcare providers and staff, provider incompetence, discriminatory and oppressive practices, and exclusionary forms and processes emerged as barriers to enacted health literacy among participants. Conversely, facilitators of enacted healthcare literacy included positive experiences with healthcare providers and staff, and inclusive forms and processes.

The Experiences of Transmasculine People with Contraception and Menstruation: A Literature Review of Qualitative and Mixed Method Studies

Purpose: A paucity of research exists concerning transmasculine experience with contraception and menstruation, despite these being possible sources of dysphoria. Understanding how transmasculine people navigate contraception and menstruation can help improve the quality of care provided for this community. This literature review consequently aims to synthesize the existing qualitative and mixed methodology literature on how transmasculine people experience and navigate contraception and menstruation. Methods: A systematically guided literature review was conducted on March 15, 2020, using CINAHL, EMBASE, Medline, PsychINFO, and Web of Science. Qualitative and mixed method studies written in English were included if (i) participants were transmasculine and older than 11 years, (ii) the research question focused on contraception and/or menstruation in the transmasculine community, and (iii) the study incorporated primary data. No publication time restrictions were placed. The analysis followed a meta-ethnographic approach, with the minority stress model and social norms theory used for guidance. Results: Five studies were found eligible for review, all published after 2015 and conducted in the United States. The majority of the total 360 participants were White and of a higher socioeconomic position. Three main thematic categories were present: (i) concerns with hormonal contraception use, including gender dysphoria and worries about interactions with testosterone; (ii) discrimination and fears around seeking health care, especially concerning the assumptions made by practitioners; and (iii) community as a positive influence, particularly for normalizing menstruation for transmasculine people. Conclusion: The data collected support the need for increased research concerning the interaction between hormonal contraception and testosterone. Reflection on assumptions, even ones made in an attempt to be supportive, can improve physician and transmasculine patient relationships. Finally, community normalization can be a powerful tool to decrease feelings of dysphoria around menstruation, and community voices should be included in all educational material concerning menstruation and contraception.

The role of ethical analysis in conducting a health technology assessment of medical treatments for gender dysphoria

Objectives

Treatment seeking for gender dysphoria (GD) has increased manifold in western countries. This has led to increased interest on evidence-base of treatments, but also discussions related to human rights, identity politics, gender-related structures, and medicalization. Combining these discourses into coherent health policy is difficult. Health technology assessment (HTA) is the golden standard for assessing whether a medical intervention should be included in a health system. A comprehensive HTA should include medical, safety, and cost-utility perspectives, but often also ethical, societal, organizational, and legal concerns. Still, ethics is often omitted in practice. This paper aims to demonstrate how integrated ethical analysis influenced a HTA of complex and controversial topics like GD.

Methods

A HTA of medical treatments of GD was conducted using integrated ethical analysis based on the EUnetHTA-model. This integrates ethical thinking into the whole HTA, explicitly analyses ethical topics, and balances arguments using several ethical theories.

Results

Integrating ethics had a significant impact on the HTA process and recommendations. It influenced how the HTA was planned and executed, emphasized autonomy and justice when creating the recommendations, and helped the workgroup to understand the complexity of combining different stakeholders’ discourses. Tensions between scientific evidence, expectations, and values became explicit.

Conclusions

Comprehensive HTA provides an important, integrative approach to considering complex and controversial topics in health systems. HTA emphasizes multidisciplinary and multi-stakeholder approach but simultaneously forces a pragmatic, results-oriented, and evidence-based approach on all argumentation. Ethical analysis can facilitate interactions between stakeholders, bridge different discourses, and help formulate widely acceptable guidelines and policy decisions.

Improving "Life Chances": Surveying the Anti-Transgender Backlash, and Offering a Transgender Equity Impact Assessment Tool for Policy Analysis

Transgender inclusion within policy is critical yet often missing. We propose a policy tool to assesses human rights, access to resources and opportunities, language, and implications for transgender and nonbinary individuals. Acknowledging trans communities as standard policy practice can serve as an essential practice to shift dialogue and norms.

Health and Health Care Among Transgender Adults in the United States

Transgender (trans) communities in the USA and globally have long organized for health and social equity but have only recently gained increased visibility within public health. In this review, we synthesize evidence demonstrating that trans adults in the USA are affected by disparities in physical and mental health and in access to health care, relative to cisgender (nontrans) persons. We draw on theory and data to situate these disparities in their social contexts, explicating the roles of gender affirmation, multilevel and intersectional stigmas, and public policies in reproducing or ameliorating trans health disparities. Until recently, trans health disparities were largely made invisible by exclusionary data collection practices. We highlight the importance of, and methodological considerations for, collecting inclusive sex and gender data. Moving forward, we recommend routine collection of gender identity data, an emphasis on intervention research to achieve trans health equity, public policy advocacy, and investment in supporting gender-diverse public health leadership. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Trans*Forming Access and Care in Rural Areas: A Community-Engaged Approach

Research indicates that rural transgender and gender diverse (TGD) populations have a greater need for health services when compared with their urban counterparts, face unique barriers to accessing services, and have health disparities that are less researched than urban TGD populations. Therefore, the primary aim of this mixed-methods study (n = 24) was to increase research on the health care needs of TGD people in a rural Appalachian American context. This study was guided by a community-engaged model utilizing a community advisory board of TGD people and supportive parents of TGD children. Quantitative results indicate that travel burden is high, affirming provider availability is low, and the impacts on the health and mental health of TGD people in this sample are notable. Qualitative results provide recommendations for providers and health care systems to better serve this population. Integrated mixed-methods results further illustrate ways that rural TGD people and families adapt to the services available to them, sometimes at significant economic and emotional costs. This study contributes to the small but growing body of literature on the unique needs of rural TGD populations, including both adults and minors with supportive parents, by offering insights into strategies to address known disparities.

Perioperative Considerations for Person-Centered Gender-Affirming Surgery

With more than 1 million people identifying as transgender in the United States alone, the likelihood of encountering a transgender patient and their family of choice in the perioperative setting is very high. A lack of data exists to equitably inform transgender-specific issues, as well as the associated morbidity during the transgender reassignment perioperative period. Anaesthesiologists should actively acquire the knowledge and skills needed to inclusively and respectfully manage these patients and be aware of their unique physiological and psychosocial needs. The pre-operative approach includes a detailed history, focusing on the patients cross-sex hormone treatment (CSHT) regimen and associated medical conditions. An in-depth understanding of commonly used hormones such as estrogen and testosterone and their effect in the perioperative periods is essential. The physical examination should be relevant to the anatomy that is currently present while taking into consideration feminising and masculinising procedures (e.g., genioplasty, thyroid cartilage augmentation), how these interventions alter the anatomy, and potential airway complications. Laboratory results should be interpreted with care – and with expert assistance if needed - as hormone therapy might affect reference values. In addition, risk assessment tools should be used with caution since they often include sex in their scoring system but do not account for the use of CSHT. Intraoperative considerations include urethral catheter placement, drug dosing, and drug interactions that are commonly encountered in the transgender patient. Special attention should be taken in transgender females who have undergone vocal feminization, as case reports have described unexpected difficult airway management. A multimodal approach, which includes regional blocks and attention to pre-existing chronic pain conditions, should be employed as part of the post-operative pain management plan. The post-operative nausea and vomiting risk has not yet been established in this population, requiring appropriate anti-emetic prophylaxis. Despite societal advances that improve transgender health, the medical community still lacks empirical evidence to effectively mitigate the distinctive challenges confronted by this at-risk population.

Culturally safe, high-quality breast cancer screening for transgender people: A scoping review protocol

AIM

To develop evidence-based recommendations for provision of culturally safe, high-quality services for breast cancer screening for transgender people.

DESIGN

The scoping review will follow the JBI methodological guidance for scoping reviews.

METHODS

A search using MEDLINE (PubMed), Embase (Ovid), Scopus, the Cochrane Library, including the Cochrane Methodology Register, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the World Health Organization, Australia Government Department of Health and Google Scholar will be undertaken. The review will include people of any age and ethnicity defined in the source of evidence as transgender. The review will include individuals who have used gender-affirming interventions or not and sources of evidence that report information relevant to the provision of culturally safe, high-quality breast cancer screening services for transgender people. English language sources of evidence published from database inception with information from any country will be eligible for inclusion. Sources will be screened for inclusion by three independent reviewers. Results will be extracted using a purpose-built tool and presented in relation to the review questions and objective in the final report using tables, figures and corresponding narrative. Project funding was approved by the Australian Government Department of Health in June 2020.

DISCUSSION

There are a range of factors that impact on the equity of health access and outcomes for people who are not cisgender. Transgender people are at risk of breast cancer but there is relatively little evidence about how their risks may or may not differ substantially from cis-gendered individuals and little guidance for health providers to ensure inclusive, culturally safe, high-quality breast cancer screening services for both transgender males, transgender females and gender diverse people who may not identify as male or as female.

IMPACT

It is important to provide culturally safe, high-quality services for breast cancer screening for transgender people.