Waiting to be seen: social perspectives on trans health

'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.

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.

Understanding the health care needs of transgender and gender diverse people engaging with rural Australian sexual health centres: a qualitative interview study

BACKGROUND

Although there is a presumption that LGBTQ+ people living in rural Australia will have poorer health outcomes than those living in metropolitan areas, minimal research has focused specifically on the perspectives of transgender and gender diverse (henceforth referred to as 'trans') people living in these regions. The purpose of this study was to understand what health and wellbeing means to trans people in a regional or rural community and identify their health needs and experiences.

METHODS

A total of 21 trans people were recruited through two regional sexual health centres (SHC) and interviewed between April and August 2021. Data were analysed via reflexive thematic analysis. This paper focuses on participants' accounts of health and wellbeing regarding gender affirmation, the experience of rural living, respectful holistic care, safety in rural communities, isolation, loneliness, and employment.

RESULTS

The experience of living rurally can have both positive and negative impacts on the experiences of trans people. Participants reported experiences of stigma and discrimination, reduced employment opportunities and limited social interactions, which led to feelings of isolation and loneliness; however, they also reported high quality of care, particularly with the specific SHCs which supported this research.

CONCLUSION

Living rurally can impact both positively and negatively on the health and wellbeing of trans peoples, and the experiences of living in this environment are diverse. Our findings challenge the perception that rural trans people experience only poor health outcomes and shows the difference that key health services such as SHCs can make in supporting trans health.

Knowledge of Australia's My Health Record and factors associated with opting out: Results from a national survey of the Australian general population and communities affected by HIV and sexually transmissible infections

My Health Record is Australia's national, digital, personal health record system. All Australians have a record in the system unless they choose to opt out of it. Concerns about privacy, security and unwanted sharing of data, particularly in marginalised populations, may impede its use. We conducted a national, online survey of Australians' attitudes to digital health in April-June 2020. The sample (N = 2,240) was recruited from the general population and four priority populations affected by HIV and other sexually transmissible infections: gay and bisexual men, people living with HIV, sex workers, and trans and gender diverse people. This analysis assesses factors associated with greater knowledge of My Health Record and the likelihood of opting out of the system. Due to increased concerns about data privacy and misuse, we hypothesised that priority population members would know more about and be more likely to opt out of the system. We found that most of the sample (71.2%) knew little about My Health Record and 29.4% had opted out of the system. Greater knowledge of My Health Record was associated with younger age, having a university degree, having one or more health conditions, and being trans or gender diverse. Being a student, unemployed, receiving government benefits, or having poor self-reported health, were associated with less knowledge. Opting out of My Health Record was associated with having a university degree, one or more health conditions, and being a priority population member. The likelihood of opting out was lower among people born overseas, residents of Queensland, and people who were students, unemployed, or receiving government benefits. We recommend additional investment in community-based education to address people's concerns about My Health Record and support people to use the system without compromising their health care, privacy, or security. Opting out may be a legitimate choice for people who perceive more risks than benefits from the system.

Engaging Stigmatised Communities in Australia with Digital Health Systems: Towards Data Justice in Public Health

Introduction

In 2018, following government policy changes to Australia's national electronic health record system, 'My Health Record', consumer advocates-including organisations representing people living with HIV, people who use drugs and sex workers-raised concerns about privacy and data security. Responding to these controversies, this study explores the practical, ethical and political complexities of engaging stigmatised communities with digital health systems.

Methods

We conducted 16 qualitative semi-structured interviews in 2020 with key informants representing communities who experience stigma, discrimination and marginalisation in Australia. These communities included people living with HIV, sex workers, people who inject drugs, gay and bisexual men and transgender and gender diverse people. We conducted a reflexive thematic analysis.

Results

Key informants were sceptical of proposed benefits of electronic health records for their communities, and concerned about privacy risks and the potential for discrimination. Meaningful consultation, consent mechanisms and tackling structural stigma were raised as solutions for engaging communities.

Conclusions

Although communities could benefit from being included in digital health systems, significant cultural, legal and social reforms from government were believed to be necessary to build trust in digital health systems. We argue that these forms of data justice are necessary for effective future systems.

Policy Implications

Engaging stigmatised communities-including in relation to gender, sexuality, sex work, drug use, HIV-requires a commitment to data justice. The design and implementation of digital health systems requires investment in ongoing and meaningful consultation with communities and representative organisations.

'Don't think that we die from AIDS': Invisibilised uncertainty and global transgender health

The invisibilisation of social groups in health research and survey data is a source of medical uncertainty, long seen as a hallmark of the medical field. However, scholarship has not thoroughly assessed how medical uncertainty is structured by state-level processes and global health agendas, especially for people beyond the Global North. This article introduces invisibilised uncertainty as a type of medical uncertainty structured by global organisational and state-level priorities, which can invisibilise social groups and health problems from research and data collection, exacerbating medical uncertainty and health disparities for people worldwide. Based on 14 months of fieldwork in Thailand and in-depth interviews with 62 participants, the article illuminates how state-level processes and global clinical research agendas have structured knowledge gaps and uncertainties for Thai transgender women. As omissions in health research and data collection become embodied on a world scale, the article expands our understandings of how gendered health disparities are structured nationally and globally. It advances a sociology of medical ignorance by analysing the uneven landscape of holistic transgender health research, parsing how institutional dynamics can prioritise or invisibilise people and health issues in research and data, and structure uncertainties.

Understanding access to healthcare for gender diverse young people: a critical review of the literature

Gender diverse young people face well-documented physical, mental and sexual health disparities compared to the general population. Differential access to healthcare is a key driver of these inequities and literature highlights high unmet healthcare need among members of this group. Healthcare access has been described through a model that defines five dimensions of health services: approachability; acceptability; availability and accommodation; affordability; and appropriateness; and five abilities of health service consumers that interact with these dimensions: the abilities to perceive, seek, reach, pay and engage. This comprehensive literature review examined barriers to and facilitators of healthcare access among gender diverse young people using the lens provided by this model as it relates to dimensions of access at the health service level and/or the abilities of health service users. We advocate expansion of this model to incorporate demand- and supply-side barriers and facilitators of access, and important structural factors including the gender binary health system framework, intersectionality and stigma. Findings highlight the need for improvements to healthcare provider education and the participatory redesign of health services with a focus on intersectionality, individually-tailored service provision and healthcare that is responsive to the unique needs of gender diverse young people.

Navigating trans visibilities, trauma and trust in a new cervical screening clinic

Trans and gender diverse people are globally recognised as being under-served in clinical services, with significant implications for their health. During a national reorientation of the Australian cervical screening programme - from Papanicolaou smears to human papillomavirus screening - we conducted interviews with 12 key informants in cancer policy, sexual and reproductive health and trans health advocacy to understand how trans people's needs and experiences were being accounted for and addressed in health policy and practice. Themes captured the complexities of increasing visibility for trans people, including men and non-binary people with a cervix. These complexities reflect the extensive system and cultural change required in asking policymakers and practitioners to think differently about who is at risk of a disease typically associated with cisgender women. Informants drew on the language of trauma to explain the resistance many trans people feel when engaging with clinical services, particularly relating to sexual and reproductive health. In doing so, they argued for increasing resources and processes to elicit trans people's willingness to put their trust in such services. Thinking critically about the relationship between the politics of trans visibilities, trauma and trust can support effective and inclusive approaches to transgender health.

Diversity via datafication? Digital patient records and citizenship for sexuality and gender diverse people

In 2018, the Australian Government adopted an ‘opt-out’ strategy to increase participation in My Health Record (MHR), the national digital patient record system. Opt out was rationalised through discourse on the universal right to health. Media controversy ensued due to privacy fears, security and commercial exploitation of patient information. LGBT community organisations warned that people with complex health needs should consider their privacy and legal situation when deciding whether or not to opt out of MHR. With reference to the health needs of sexuality and gender diverse people, we examine MHR’s rights universalism, possessive individualism, and state-based rationalisation of health governance. MHR hails all but no-one in particular, erasing diversity and straightwashing data medicine. It is a technological solution to state-based imperatives for health governance, an emphasis that does not serve minority communities or address health needs that attract stigma and prejudice. We counterpose these effects with citizenship framings seated in critical approaches to data assemblages and sexuality and gender diversity. We suggest ways in which data medicine, of which MHR is but one example, can be made more relevant and effective for individuals and communities whose healthcare is poorly served by mainstream health systems.

Sexual experience, relationships, and factors associated with sexual and romantic satisfaction in the first Australian Trans & Gender Diverse Sexual Health Survey

Background: Sexual and romantic satisfaction are important aspects of sexual health and wellbeing, but they have not been thoroughly investigated among transgender and gender diverse ('trans') people in Australia. Aims: To address this gap and improve sexual health and wellbeing, we assessed the sexual behavior and relationships of a national sample of trans people in Australia, and factors associated with sexual and romantic satisfaction. Methods: We conducted a national survey of trans people from Australia in October-November 2018. Results: The sample included 1,613 trans participants, of whom 353 (21.9%) were men, 397 (24.6%) were women and 863 (53.5%) were non-binary. Over 70% of the sample had been sexually active in the previous year, and 56.9% were in a relationship, but only 32.4% were satisfied with the sexual aspects and 47.1% with the romantic aspects of their lives. Sexual satisfaction was associated with younger age, being asexual, having more trans friends, more frequent sex, and using illicit drugs in the context of sexual activity. Anxiety or fear about sex was associated with less sexual satisfaction, as was being in an open relationship. Romantic satisfaction was associated with younger age, having non-binary partners, and being in a current relationship (particularly a monogamous one). Recent distress, anxiety, or fear about sex were associated with less romantic satisfaction. Conclusion: Participants reported a broad range of sexual relationships, but low levels of satisfaction with the sexual and romantic aspects of their lives. The findings underscore the importance of supportive partners, access to social support and peer networks of trans people, as well as access to mental health support and sex-positive, trans affirming counseling in sexual health services.