'Bye-bye boobies': normativity, deservingness and medicalisation in transgender medical crowdfunding

'Financial fallout' in the US biopharmaceutical industry: Maximizing shareholder value, regulatory capture, and the consequences for patients

Patients are suffering the consequences of financialization - as shareholders demand high returns from pharmaceutical companies, pharmaceuticals squeeze profits out of top-selling products, and insurers charge higher premiums for limited coverage, the impact of financialization cascades across the value chain to compound the burden of cost for patients. This article offers a novel theoretical perspective and methods for understanding how "financial fallout" has impacted the pharmaceutical value chain, health systems, and patients. Financial fallout describes the cascade of consequences characteristic of and essential to industries reshaped by financialization. It characterizes how the effects of financialization have become so thoroughly engrained in industries and societies as to seem inevitable and how the consequences are also devastating, like the fallout that follows nuclear disasters. The research represented here examines how processes of financial fallout: 1) cascade across the pharmaceutical value chain from innovation to commercialization; 2) are enacted through 'regulatory capture' as regulations meant to safeguard the public from the exigencies of the market ultimately serve the interests of industry; and 3) have devastating consequences for patients who need access to life-saving therapies. The analysis is developed through the example of the market for monoclonal antibodies in the US, and the specific case of Keytruda - one of the top-selling monoclonal antibodies marketed for cancer therapy, which generated over 14 USD billion in revenue in 2020 and 17 billion in 2021. It traces how processes of financial fallout cascade down the value chain to impact health systems and compound the cost of care for patients. Financial fallout signals dire trends in providing health services and access to medicines. It diagnoses how our options for saving lives and improving health are overdetermined by and infused with the interests of financial capital.

A critical analysis of trans-visibility through online medical crowdfunding

In contexts where many people face barriers to accessing gender-affirming care through public systems, some turn to online crowdfunding to fundraise for private care pathways. Crowdfunding platforms invite people to share personal information, stories, and photos publicly, in order to elicit donations. In this article we draw on empirical data from a multimethodological three-year study of medical crowdfunding in Aotearoa New Zealand, with a focus on people crowdfunding for medical transition services. We apply a lens of 'visibility' to analysis of focus groups, interviews, case studies, and campaign pages, presenting findings on who was present and absent (with a focus on binary gender, and whiteness), and who was the assumed or expected audience (with a focus on cis publics). We describe how campaigns were defined by efforts to make trans bodies legible, and campaign requests competitive, through reference to narrow and medicalised frames of dysphoria, suffering, and transformation via medical intervention. We contribute to more comparative work in the literature on crowdfunding by highlighting how these globalised digital technologies are situated in the particular (demographic, cultural, and structural) contexts of Aotearoa New Zealand. We call attention to crowdfunding as a relational practice, in which the public marketisation of the self can have both individual consequences related to privacy and outing, and social consequences, in the reinforcing of trans-normativities. Overall we argue that although crowdfunding represents an adaptive strategy for trans people trying meet their own needs, it ultimately contributes to a type of trans-visibility which is both risky and limiting.

"They Were Talking to an Idea They Had About Me": A Qualitative Analysis of Transgender Individuals' Experiences Using Dating Apps

Dating app use is common and has become particularly relevant for transgender and non-binary people seeking platonic, romantic, and sexual connections with others. In this qualitative study, 15 transgender and non-binary individuals (M = 22.67 years, SD = 3.09 years) were interviewed to explore their experiences using dating apps. Thematic analysis was used to generate themes and subthemes. Six themes were identified: 1) connection to queer community; 2) expression of gender identity on dating apps; 3) fetishization on dating apps; 4) impacts of dating apps on sexual experiences; 5) safety on dating apps; and 6) recommendations for dating app developers. Results show that dating apps are an important tool used by trans/non-binary individuals to connect with others in the queer community and find platonic, romantic, and sexual partners. However, there are concerns about their use such as fears for safety and experiences of fetishization. More research, education, and implementations of app development, including the involvement of trans and non-binary people, are needed to address these concerns.

A Content Analysis of Transgender Health and Wellness Themes Shared Through Social Media

Transgender and gender-diverse (TGD) adolescents experience limited access to gender-affirming care (GAC) and information and use social media platforms for informational and social support. We conducted conventional content analysis of posts on the platform, Tumblr and applied univariate statistics to characterize health and wellness themes represented by this content. Content was predominantly transmasculine-relevant. Posts addressing the trans health care paradigm often co-occurred with content referencing affirmation logs, the physical and emotional impact of affirmation, surgery, and unspecified medical interventions. Gender-affirming hormone therapy was the most prevalent intervention referenced in posts related to non-professional/non-licensed medical care and advice requests. Transgender and gender-diverse youth-serving individuals can use this information to mitigate harm, enhance patient education, and improve the overall well-being of TGD youth. Further research is needed to characterize the effect of content encountered on social media on pediatric patient experiences and on outcomes of GAC.

Exploring Online Crowdfunding for Cancer-Related Costs Among LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer, Plus) Cancer Survivors: Integration of Community-Engaged and Technology-Based Methodologies

BACKGROUND

Cancer survivors frequently experience cancer-related financial burdens. The extent to which Lesbian, Gay, Bisexual, Transgender, Queer, Plus (LGBTQ+) populations experience cancer-related cost-coping behaviors such as crowdfunding is largely unknown, owing to a lack of sexual orientation and gender identity data collection and social stigma. Web-scraping has previously been used to evaluate inequities in online crowdfunding, but these methods alone do not adequately engage populations facing inequities.

OBJECTIVE

We describe the methodological process of integrating technology-based and community-engaged methods to explore the financial burden of cancer among LGBTQ+ individuals via online crowdfunding.

METHODS

To center the LGBTQ+ community, we followed community engagement guidelines by forming a study advisory board (SAB) of LGBTQ+ cancer survivors, caregivers, and professionals who were involved in every step of the research. SAB member engagement was tracked through quarterly SAB meeting attendance and an engagement survey. We then used web-scraping methods to extract a data set of online crowdfunding campaigns. The study team followed an integrated technology-based and community-engaged process to develop and refine term dictionaries for analyses. Term dictionaries were developed and refined in order to identify crowdfunding campaigns that were cancer- and LGBTQ+-related.

RESULTS

Advisory board engagement was high according to metrics of meeting attendance, meeting participation, and anonymous board feedback. In collaboration with the SAB, the term dictionaries were iteratively edited and refined. The LGBTQ+ term dictionary was developed by the study team, while the cancer term dictionary was refined from an existing dictionary. The advisory board and analytic team members manually coded against the term dictionary and performed quality checks until high confidence in correct classification was achieved using pairwise agreement. Through each phase of manual coding and quality checks, the advisory board identified more misclassified campaigns than the analytic team alone. When refining the LGBTQ+ term dictionary, the analytic team identified 11.8% misclassification while the SAB identified 20.7% misclassification. Once each term dictionary was finalized, the LGBTQ+ term dictionary resulted in a 95% pairwise agreement, while the cancer term dictionary resulted in an 89.2% pairwise agreement.

CONCLUSIONS

The classification tools developed by integrating community-engaged and technology-based methods were more accurate because of the equity-based approach of centering LGBTQ+ voices and their lived experiences. This exemplar suggests integrating community-engaged and technology-based methods to study inequities is highly feasible and has applications beyond LGBTQ+ financial burden research.

Supporting gender-diverse young people: the role of the nurse

Gender-diverse individuals will need to access healthcare services for various reasons, with most of this care provided outside of specialist gender services. Nurses have an important role in advocating for the specific needs of gender-diverse individuals and providing person-centred care. Therefore, they have a responsibility to ensure their knowledge of appropriate terminology and gender-affirming interventions is up to date. This article provides information about gender diversity to enhance nurses' understanding of this area to enable them to care for gender-diverse people effectively and sensitively. While the focus of this article is on gender-diverse young people, the same principles can be applied across all age groups.

An overview of Fintech applications to solve the puzzle of health care funding: state-of-the-art in medical crowdfunding

Crowdfunding is emerging as an alternative form of funding for medical purposes, with capital being raised directly from a broader and more diverse audience of investors. In this paper, we have systematically researched and reviewed the literature on medical crowdfunding to determine how crowdfunding connects with the health care industry. The health care industry has been struggling to develop sustainable research and business models for economic systems and investors alike, especially in pharmaceuticals. The research results have revealed a wealth of evidence concerning the way crowdfunding is applied in real life. Patients and caregivers utilize web platform-based campaigns all over the world to fund their medical expenses, generally on a spot basis, using donation-based or even reward-based schemes, regardless of the health care system archetype (public, private insurance-based or hybrid). Academics have also focused on funding campaigns and the predictors of success (which range from social behaviour and environment to the basic demographics of the campaigners and their diseases) and on social and regulatory concerns, including heightened social inequality and stigma. While equity crowdfunding is disrupting the way many ventures/businesses seek capital in the market, our research indicates that there are no relevant or consistent data on the practice of medical equity crowdfunding in health care, apart from a few anecdotal cases.

Mapping Accessibility to Fertility Preservation for Trans Masculine Individuals in the Netherlands

Purpose: Since 2014 in the Netherlands, sterilization is no longer required for legal gender affirmation. Access to fertility preservation (FP) options is indispensable to grant equal reproductive rights to this population. This study aims to map existing literature on barriers and enabling factors for trans masculine individuals to access FP in the Netherlands after 2014. Methods: A scoping review method was conducted, including a database and a hand search complemented with informal consultations. Literature between 2014 and 2021 was searched. Results: A total of 38 peer-reviewed articles and 22 complementary gray literature sources were retrieved. Thematic analysis identified seven common themes: biological, psychological, training, language, law and legislation, economic, and sociocultural. The themes were clustered as patient-, health care provider (HCP)- and environment-related. Conclusion: The Netherlands offers progressive legislation and accommodating insurance agreements that favor FP for trans masculine individuals. However, the current readiness of HCPs to provide adapted and tailored care is arguable, and the capacity to access appropriate health services for trans masculine individuals is largely nonexistent outside of highly specialized health institutions. The implementation of both formal and informal education training programs for HCPs on transgender and gender diverse health needs-as well as inclusive language use-could benefit this community at large.

Like a Grinding Stone: How Crowdfunding Platforms Create, Perpetuate, and Value Health Inequities

This article explores how inequities are reproduced by, and valued within, the increasingly ubiquitous world of medical crowdfunding. As patients use platforms like GoFundMe to solicit donations for health care, success stories inundate social media. But most crowdfunders experience steep odds and marginal benefits. Drawing on the problematic figure of the "black box" in health disparities research and technology studies, I offer ethnography as a tool for unpacking often inscrutable and complex pathways through which online platforms amplify inequities. By leveraging both online and traditional research strategies-a platform analysis and paired narratives of crowdfunders' disparate experiences, drawn from open-ended interviews-this article explores how inequities are created and experienced by users. The analysis highlights how inequities are simultaneously central to the functioning of this marketplace and occluded by its platform design. Consequently, crowdfunding is concealing health inequities while shifting public values about who is entitled to health care, and why.

[Self-assessment of healthcare workers regarding the management of trans people in a university hospital]

INTRODUCTION

Trans people face more barriers when seeking healthcare than the cisgender population probably due to a lack of knowledge, education and comfort of healthcare workers. The purpose of this study was to assess the knowledge and comfort felt by healthcare professionals in managing trans people in a French university hospital.

METHODS

A self-questionnaire was emailed to healthcare professionals working in departments usually involved in the care of trans people in a French university hospital "not specialized" in medical and surgical gender transition. The questionnaire included demographic questions and Likert scales regarding their knowledge and comfort in taking care of trans people. Responses on the 7-point Likert scales were categorized into "low", "medium" and "high" groups, and responses on the 5-point Likert scales were categorized into "in favour", "neutral" and "against" groups.

RESULTS

One hundred and two (29%) healthcare professionals answered the questionnaire. Half worked in surgical departments (urology, plastic surgery, gynecology), 24% worked in medical departments (endocrinology, reproductive medicine, cytogenetics) and 26% worked in psychiatry. The majority (60.3%) rated their level of knowledge as "low" and 39.7% as "medium". Sixteen percent rated their level of comfort in managing trans people as "low", 72.5% as "medium" and 11.5% as "high". A majority (77.5%) were in favor of having the costs of gender transition care covered by the national health insurance system, 16.4% were neutral and 6% were against this idea. Feelings about surgical and hormonal gender transition were overwhelmingly (96.4%) in favour or neutral and 91% were willing to get more training and education to manage trans people.

CONCLUSION

The lack of comfort felt by healthcare professionals in university hospital in managing trans people seems to be related to a lack of knowledge and training in that field and not to a disagreement with the need of transgender healthcare.

LEVEL OF EVIDENCE

3.

A cross-sectional study of social inequities in medical crowdfunding campaigns in the United States

Americans are increasingly relying on crowdfunding to pay for the costs of healthcare. In medical crowdfunding (MCF), online platforms allow individuals to appeal to social networks to request donations for health and medical needs. Users are often told that success depends on how they organize and share their campaigns to increase social network engagement. However, experts have cautioned that MCF could exacerbate health and social disparities by amplifying the choices (and biases) of the crowd and leveraging these to determine who has access to financial support for healthcare. To date, research on potential axes of disparity in MCF, and their impacts on fundraising outcomes, has been limited. To answer these questions, this paper presents an exploratory cross-sectional study of a randomized sample of 637 MCF campaigns on the popular platform GoFundMe, for which the race, gender, age, and relationships of campaigners and campaign recipients were categorized alongside campaign characteristics and outcomes. Using both descriptive and inferential statistics, the analysis examines race, gender, and age disparities in MCF use, and tests how these are associated with differential campaign outcomes. The results show systemic disparities in MCF use and outcomes: people of color (and black women in particular) are under-represented; there is significant evidence of an additional digital care labor burden on women organizers of campaigns; and marginalized race and gender groups are associated with poorer fundraising outcomes. Outcomes are only minimally associated with campaign characteristics under users' control, such as photos, videos, and updates. These results corroborate widespread concerns with how technology fuels health inequities, and how crowdfunding may be creating an unequal and biased marketplace for those seeking financial support to access healthcare. Further research and better data access are needed to explore these dynamics more deeply and inform policy for this largely unregulated industry.

Exploring crowdfunding campaigns for abortion services

OBJECTIVES

To examine the use of crowdfunding to pay for abortion services for individuals in the United States.

STUDY DESIGN

Cross-sectional analysis of data abstracted from publicly available campaigns for abortion services on four major crowdfunding sites.

RESULTS

Among 92 crowdfunding campaigns, the median amount requested was $610 (IQR $500-$1000), the median raised was $0 (IQR $0-$444), and 19 (21%) campaigns successfully reached their fundraising goal. Campaign success did not differ by state abortion policy, but campaigns written in third person or describing maternal/fetal diagnoses raised significantly more money.

CONCLUSIONS

Although individuals use crowdfunding to finance abortion services, the success rate is low.

Spatially exploring the intersection of socioeconomic status and Canadian cancer-related medical crowdfunding campaigns

OBJECTIVES

Medical crowdfunding is a rapidly growing practice where individuals leverage social networks to raise money for health-related needs. This practice has allowed many to access healthcare and avoid medical debt but has also raised a number of ethical concerns. A dominant criticism of this practice is that it is likely to increase inequities in access to healthcare if persons from relatively wealthy backgrounds, media connections, tech-savvy and educational attainments are best positioned to use and succeed with crowdfunding. However, limited data has been published to support this claim. Our objective in this paper is to assess this concern using socioeconomic data and information from crowdfunding campaigns.

SETTING

To assess this concern, we present an exploratory spatial analysis of a new dataset of crowdfunding campaigns for cancer-related care by Canadian residents.

PARTICIPANTS

Four datasets were used: (1) a medical crowdfunding dataset that included cancer-related campaigns posted by Canadians, (2) 2016 Census Profile for aggregate dissemination areas, (3) aggregate dissemination area boundaries and (4) forward sortation area boundaries.

RESULTS

Our exploratory spatial analysis demonstrates that use of crowdfunding for cancer-related needs in Canada corresponds with high income, home ownership and high educational attainment. Campaigns were also commonly located near city centres.

CONCLUSIONS

These findings support concerns that those in positions of relative socioeconomic privilege disproportionately use crowdfunding to address health-related needs. This study was not able to determine whether other socioeconomic dimensions such as race, gender, ethnicity, nationality and linguistic fluency are also correlated with use of medical crowdfunding. Thus, we call for further research to explore the relationship between socioeconomic variables and medical crowdfunding campaigning to explore these other socioeconomic variables and campaigns for needs unrelated to cancer.

Inequalities in Crowdfunding for Transgender Health Care

Purpose: An emerging body of research analyzes the scope, ethics, and inequalities of web-based crowdfunding to raise money for medical expenses related to illness or injury. To date, little research has investigated how transgender communities utilize crowdfunding expenses related to gender affirming medical care.

Methods: Using GoFundMe.com, we created a data set of 391 crowdfunding campaigns for gender-affirming care created from 2012 to 2016. In addition to descriptive statistics of recipient demographics and campaign financials, we conducted hierarchical multiple regression analyses to determine the factors associated with financial outcomes of fundraising for medical expenses.

Results: Findings indicate that the majority of campaigns were used to fund chest surgeries among young, white, binary-identified trans men in the United States. Few campaigns met their fundraising goal. Being a trans man whose Facebook community shares the crowdfunding campaign is predictive of meeting a higher percentage of the fundraising goal, whereas being a trans woman whose Facebook community shares the campaign is predictive of raising more money.

Conclusion: The use of crowdfunding for gender affirming highlights the difficulties that transgender persons face with using private and public health care programs to fund medically necessary care. Health care providers should exercise caution in recommending crowdfunding as a viable strategy to raise money for out-of-pocket costs.