The Need of Patient Involvement in Transgender Health Care Research

Direct and vicarious exposure to healthcare discrimination and erasure among transgender and gender independent individuals: Testing the indirect effect of mistrust in healthcare on utilization behaviors

RATIONALE

Direct exposure to gender identity-related discrimination and erasure among the transgender and gender independent (TGI) population are associated with healthcare underutilization, which may further exacerbate the health disparities that exist between this population and cisgender individuals in the United States (U.S.). Although the impacts of direct exposure to healthcare discrimination and erasure may have on TGI individuals are known, exposure to such harm vicariously (i.e., through observation or report) is underexplored.

OBJECTIVE

The present study examined the relationships among direct and vicarious gender identity-related healthcare discrimination and erasure exposure and past-year healthcare utilization.

METHOD

Gender identity-based mistrust in healthcare was also assessed, as a mechanism through which direct and vicarious gender identity-related healthcare discrimination and erasure predict healthcare utilization behaviors among a sample (N = 385) of TGI adults in the U.S., aged 18 to 71 recruited online.

RESULTS

Results indicated direct lifetime and vicarious healthcare discrimination and erasure exposure significantly predicted past-year healthcare underutilization when participants anticipated encountering gender identity-related healthcare discrimination. Mediational analyses indicated that higher levels of exposure to direct lifetime and vicarious healthcare discrimination and erasure were related to higher levels of mistrust in healthcare, through which past-year underutilization was significantly related.

CONCLUSIONS

These findings are vital to informing healthcare practice and policy initiatives aimed at ensuring the barriers that deleteriously influence the accessibility of healthcare among TGI individuals are ameliorated.

Research priorities in trans health: a Delphi-study

Purpose

Progress has been made in understanding trans health needs, but research priorities are often set by policy or healthcare professionals without trans input, which may not reflect public needs. Our study sought to identify trans health research priorities in France from both researchers and the trans community.

Methods

Expert stakeholders (health and social sciences professionals, trans individuals, and their families) answered a three-round Delphi survey on trans health research priorities. The first round involved an open-ended questionnaire, analyzed qualitatively. In the second round, participants ranked research propositions from round one using a Likert scale. The study's second phase involved a two-hour workshop with experts and trans individuals.

Results

53 participants (32% trans individuals/relatives, 60% health professionals) contributed 217 responses to open-ended questions, leading to 44 research priorities. After the two voting rounds, a total of five proposals reached a strong consensus cut-off and were considered as the main research priorities: evaluation of the effect of puberty blocker use in trans children and adolescents (95%), evaluation of the effect of supporting trans children and adolescents (92%), study of the support systems available for trans youth and their parents (86%), persistence of trans identity around puberty (prevalence, persistent persons characteristics) (86%), and needs assessment survey of the support for adolescents and their families (83%). Thirteen other proposals were considered moderate priorities.

Conclusion

The main consensus in our French study concerned research on trans-youth care and support needs. Our results may guide further trans-health research that meets the public's needs and desires.

Introduction to healthcare for transgender and gender-diverse people

This editorial provides a broad introduction to transgender health for transgender and gender-diverse people. Following a brief description of the history of transgender and gender-diverse people, the development of medical treatment is discussed, together with the use of appropriate terminology and language. The content largely draws attention to the guidance in the Standards of Care for the Health of Transgender and Gender Diverse People Version 8 developed by the World Professional Association for Transgender Health (WPATH) and published in 2022. Further key areas addressed are as follows. • The use of names and pronouns. • Population estimates of transgender and gender diverse people. • Diagnostic classification systems in transgender health. • A wide range of gender-affirming medical interventions, including hormones and surgeries. • Ethical considerations for research with transgender and gender diverse populations.

Prevalence and associated risk factors of HIV infections in a representative transgender and non-binary population in Flanders and Brussels (Belgium): Protocol for a community-based, cross-sectional study using time-location sampling

Introduction

HIV prevalence and sexual risk have been estimated very high for transgender people. However, the limited sampling and data collection methods used in current research on transgender people potentially led to overrepresentation and generalisation of people at risk for HIV. Current HIV prevalence estimates in transgender populations are generalised from studies mainly focusing on transgender women engaging in sex work. Moreover, studies focusing on non-binary people, who identify with a broad range of identities beyond the traditional male and female gender identities, are scarce.

Objectives

To estimate the HIV prevalence rate in the Flemish and Brussels (Belgium) transgender population, including transgender women, transgender men and non-binary people, and to identify the associated risk factors.

Methods

In this community-based cross-sectional study, self-identified transgender and non-binary (TGNB) people will be recruited through a two-stage time-location sampling approach. First, community settings in which TGNB people gather will be mapped to develop an accurate sampling frame. Secondly, a multistage sampling design is applied involving a stratification based on setting type (healthcare facilities vs outreach events), a selection of clusters by systematic sampling and a simple random selection of TGNB people within each cluster. Participants will complete an electronic self-reported survey to measure sociological, sexual and drug-using behaviors (risk factors) and oral fluid aliquots will be collected and tested for HIV antibodies. Logistic regression models will be used to evaluate risk factors independently associated with HIV infection. The presented study is registered at ClinicalTrials.gov (NCT04930614).

Discussion

This study will be the first to investigate the HIV prevalence rates and associated risk behaviors in an accurate representation of the TGNB population in a Western European country. The findings will globally serve as a knowledge base for identifying subgroups at risk for becoming infected with HIV within TGNB people and to set up targeted prevention programs.

Setting a research agenda in trans health: An expert assessment of priorities and issues by trans and nonbinary researchers

BACKGROUND

This article is by a group of trans and nonbinary researchers and experts in the field of trans health who have conducted an analysis of trans health research needs.

AIMS

To highlight topics that need further research and to outline key considerations for those conducting research in our field.

METHODS

The first author conducted semi-structured interviews with all coauthors, and these were used to create a first draft of this manuscript. This draft was circulated to all authors, with edits made until consensus was reached among the authors.

RESULTS

More comprehensive long-term research that centers trans people's experiences is needed on the risks and benefits of gender affirming hormones and surgeries. The trans health research field also needs to have a broader focus beyond medical transition or gender affirmation, including general health and routine healthcare; trans people's lives without, before, and after medical gender affirmation; and sexuality, fertility, and reproductive healthcare needs. More research is also needed on social determinants of health, including ways to make healthcare settings and other environments safer and more supportive; social and legal gender recognition; the needs of trans people who are most marginalized; and the ways in which healing happens within trans communities. The second part of this article highlights key considerations for researchers, the foremost being acknowledging trans community expertise and centering trans community members' input into research design and interpretation of findings, in advisory and/or researcher roles. Ethical considerations include maximizing benefits and minimizing harms (beneficence) and transparency and accountability to trans communities. Finally, we note the importance of conferences, grant funding, working with students, and multidisciplinary teams.

DISCUSSION

This article outlines topics and issues needing further consideration to make the field of trans health research more responsive to the needs of trans people. This work is limited by our authorship group being mostly White, all being Anglophone, and residing in the Global North.

How the COVID-19 pandemic affects transgender health care - A cross-sectional online survey in 63 upper-middle-income and high-income countries

Background

Due to the COVID-19 pandemic, access to medical care is restricted for nearly all non-acute conditions. Due to their status as a vulnerable social group and the inherent need for transition-related treatments, transgender people are assumed to be affected particularly severely by the restrictions caused by the COVID-19 pandemic.

Methods

As an ad hoc collaboration between researchers, clinicians and 23 community organizations, we developed a web-based survey in German that was translated into 26 languages. Participants were recruited via community sources, social media channels, and snowball sampling since May 2020. The present sample is based on the data collected until August 9, 2020. We assessed demographical data, health problems, risk factors, COVID-19 data (e.g., contact history), and the influence of the COVID-19 pandemic on access to transgender health care services. To identify factors associated with the experience of restrictions, we conducted multiple logistic regression analysis.

Results

5267 transgender people from 63 upper-middle-income and high-income countries participated in the study. Over 50% of the participants had risk factors for a severe course of a COVID-19 infection and were at a high risk of avoiding COVID-19 treatment due to the fear of mistreatment or discrimination. Access to transgender health care services was restricted for 50% of the participants. Male sex assigned at birth and a lower monthly income were significant predictors for the experience of restrictions to health care. 35.0% reported at least one mental health condition and 3.2% have attempted suicide since the beginning of the COVID-19 pandemic.

Discussion

Transgender people suffer under the severity of the pandemic due to the intersections between their status as a vulnerable social group, their high number of medical risk factors, and their need for ongoing medical treatment. The COVID-19 pandemic can potentiate these vulnerabilities, add new challenges for transgender people, and, therefore, can lead to devastating consequences, like severe physical or mental health issues, self-harming behavior, and suicidality.

Perspectives on expertise in teaching about transgender healthcare: A focus group study with health professional programme teaching staff and transgender community members

BACKGROUND

It is well established that transgender people experience considerable health inequities, which are sustained in part by limited teaching about transgender healthcare for trainee health professionals.

AIMS

The aim of this study was to explore the perspectives of both teaching staff from health professional education programmes and transgender community members on the best ways to teach about transgender healthcare, with a focus on ways of: 1) overcoming barriers to this teaching; and 2) involving community members in this teaching.

METHODS

A research advisory committee was convened to guide the project and included transgender community members, teaching staff from health professional programmes, and trainee health professionals in Aotearoa/New Zealand. Three preliminary focus groups were held with 10 transgender community members. These community members were then invited to act as transgender community 'ambassadors' in focus groups with teaching staff based on suggestions from the advisory committee. Six focus groups were conducted with 22 teaching staff from a range of health professional education programmes along with at least two transgender community ambassadors.

RESULTS

Teaching staff positioned themselves as lacking the expertise to teach about transgender healthcare but also as expert teachers when applying methods such as small group teaching. Transgender participants also positioned themselves as having expertise arising primarily from their own experiences and acknowledged that effective teaching about transgender healthcare would need to cover a diversity of transgender identities and healthcare outside their own experiences. Teaching staff and transgender community members were keen to pool expertise and thus overcome the shared sense of lacking the expertise to teach about transgender healthcare.

DISCUSSION

These findings provide insights into the current barriers to teaching about transgender healthcare and provide future directions for staff development on teaching about transgender healthcare and ways of safely involving transgender community members in teaching.

Mapping key stakeholders' position towards interdisciplinary transgender healthcare: A stakeholder analysis

Trans individuals experience an incongruence between their sex characteristics and their gender which might cause significant distress called gender dysphoria. Gender dysphoria is commonly treated using transition-related healthcare services, like sex hormones and surgeries, ideally in interdisciplinary settings. The stakeholder environment of an interdisciplinary transgender healthcare centre (ITHC) is considered key in delivering high-quality healthcare. Therefore, a stakeholder analysis was performed seeking to improve stakeholder relationships and service quality through an evidence-based approach. Quantitative data were collected using a questionnaire administered cross-sectionally, and covering attitude towards the ITHC, influence of and influence on stakeholders, level of knowledge about the ITHC, importance of the ITHC for stakeholders and types of interests. The analysis used primary data, collected July to August 2015. N = 79 key stakeholders were identified and n = 42 (53.2%) participated in the survey. Participants were categorised analytically into four stakeholder groups: trans groups, trans health experts, healthcare system and admin departments of the ITHC. Although participants reported low values (e.g. average values on a 5-point Likert scale; importance: 2.54; influence on the ITHC: 2.43), the attitude of the four stakeholder groups towards the ITHC were positive overall. The attitudes varied, however, depending on the group, for example trans health experts and trans groups reported the highest values for most items. The results demonstrate the importance of systematically analyzing stakeholder positions in order to make appropriate policy decisions, improving stakeholder relationships and assuring long-term high-quality healthcare provision. Subsequently, an action plan was developed, focusing on the two groups with the highest values (trans health experts, trans groups). Selected measures are discussed. If stakeholders are to play their part in providing high-quality, interdisciplinary trans healthcare, they need regular information on the latest developments and recurring feedback of their interests and requirements for the ITHC.

Transgender and gender non-conforming adult preparedness for aging: Concerns for aging, and familiarity with and engagement in planning behaviors

Background: Research on transgender and gender-nonconforming (TGNC) aging is limited. To date, most of the literature about TGNC aging has focused on discrimination (particularly in healthcare), violence and abuse, caregiving and family relations, and religiosity. Aims: The purposes of this study were to: (a) document concerns about aging among TGNC adults, including concerns that are identity-specific; (b) examine preparation for aging and end of life (i.e., familiarity and planning) among TGNC adults; and (c) examine potential differences in familiarity and planning based on gender identity. Methods: One hundred fifty-four individuals who currently or have ever identified as TGNC completed a national online survey assessing these constructs. Results: TGNC individuals reported many concerns about aging, both gender identity-specific and not. The most common aging concern was losing the ability to care for themselves followed by having to go into a nursing home or assisted living facility. The age preparatory behaviors individuals were most commonly aware of included: life insurance, wills, organ donation, regular medical checkups, living wills, durable power of attorney for healthcare, and trusts. Gender-nonconforming individuals had significantly more familiarity with age preparatory behaviors than trans feminine individuals, but had lower levels of planning to engage in age preparatory behaviors than both trans masculine and trans feminine individuals. Conclusion: The current findings highlight the need for providers to address age preparatory behaviors with TGNC individuals or provide referrals to support individuals in this planning.

Health Needs of Trans and Gender Diverse Adults in Australia: A Qualitative Analysis of a National Community Survey

There is an increasing demand for trans and gender diverse (TGD) health services worldwide. Given the unique and diverse healthcare needs of the TGD community, best practice TGD health services should be community-led. We aimed to understand the healthcare needs of a broad group of TGD Australians, how health professionals could better support TGD people, and gain an understanding of TGD-related research priorities. An anonymous online survey received 928 eligible responses from TGD Australian adults. This paper focuses on three questions out of that survey that allowed for free-text responses. The data were qualitatively coded, and overarching themes were identified for each question. Better training for healthcare professionals and more accessible transgender healthcare were the most commonly reported healthcare needs of participants. Findings highlight a pressing need for better training for healthcare professionals in transgender healthcare. In order to meet the demand for TGD health services, more gender services are needed, and in time, mainstreaming health services in primary care will likely improve accessibility. Evaluation of training strategies and further research into optimal models of TGD care are needed; however, until further data is available, views of the TGD community should guide research priorities and the TGD health service delivery.

The Gender Congruence and Life Satisfaction Scale (GCLS): Development and validation of a scale to measure outcomes from transgender health services

Background: It is vital that the treatment offered at transgender health services can be evaluated to ensure a high quality of care. However, the tools currently used to evaluate treatment at transgender health services are limited by mainly focusing on mental health or because they have been developed for binary transgender people only. This study therefore aimed to develop and validate a tool that addresses these limitations. The Gender Congruence and Life Satisfaction Scale (GCLS) was developed through reviewing the literature, conducting interviews with transgender people, and holding discussions with experts working in transgender healthcare. An initial pool of items was developed and feedback on these was obtained. The tool was then validated. Method: For the validation of the tool, a total of 789 participants (451 transgender [171 transgender females, 147 transgender males, 133 people identifying as non-binary], and 338 cisgender [254 females, 84 males]) were recruited from the United Kingdom to test the factor structure and validity of the GCLS. Results: Exploratory factor analysis retained 38 items which formed seven subscales (psychological functioning; genitalia; social gender role recognition; physical and emotional intimacy; chest; other secondary sex characteristics; and life satisfaction). These seven subscales were found to have good internal consistency and convergent validity. The GCLS was also found to be capable of discriminating between groups (e.g., people who have and have not undergone gender affirming medical interventions). Transgender and cisgender subscale norms are provided for the GCLS. Conclusion: The GCLS is a suitable tool to use with the transgender population to measure health-related outcomes for both clinical and research purposes.