Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination

Barriers, Challenges, and Decision-Making in the Letter Writing Process for Gender Transition

This article addresses the challenges that clinicians face in writing letters of support for transgender and gender-diverse clients. It addresses common but challenging clinical representations to help the reader understand the nuances associated with writing letters. Three cases are presented. The first addresses systemic challenges, the second addresses management of care, and the third addresses co-occurring mental health concerns. Recommendations for practice are provided based on the experiences included within the 3 case examples.

Transgressing gender norms in addiction treatment: Transgender rights to access within gender-segregated facilities

Despite having disproportionately high rates of substance use disorder and co-occurring health and mental health issues compared to the general population, transgender individuals experience significant barriers to accessing and engaging in addiction treatment programs. Inpatient addiction treatment centers were originally designed to treat substance-dependent heterosexual cisgender populations and, as such, feature gender-segregated housing, bathrooms, and treatment sessions. The heteronormative structural and programmatic barriers, combined with exposures to stigmatic and prejudicial attitudes, may dissuade transgender populations from benefiting from the addiction treatment they so direly need. The purpose of this article is to examine the current policy debate surrounding the rights of transgender individuals in public accommodations in the context of inpatient addiction treatment centers.

Transgender Noninclusive Healthcare and Delaying Care Because of Fear: Connections to General Health and Mental Health Among Transgender Adults

Purpose: There are many barriers to reliable healthcare for transgender people that often contribute to delaying or avoiding needed medical care. Yet, few studies have examined whether noninclusive healthcare and delaying needed medical care because of fear of discrimination are associated with poorer health among transgender adults. This study aims to address these gaps in the knowledge base.

Methods: This study analyzed secondary data from a statewide survey of 417 transgender adults in the Rocky Mountain region of the United States. Independent variables included noninclusive healthcare from a primary care provider (PCP) and delay of needed medical care because of fear of discrimination. Dependent variables assessed general health and mental health.

Results: Transgender individuals who delayed healthcare because of fear of discrimination had worse general health in the past month than those who did not delay or delayed care for other reasons (B=−0.26, p<0.05); they also had 3.08 greater odds of having current depression, 3.81 greater odds of a past year suicide attempt, and 2.93 greater odds of past year suicidal ideation (p<0.001). After controlling for delayed care because of fear of discrimination, having a noninclusive PCP was not significantly associated with either general health or mental health.

Conclusion: This study suggests a significant association between delaying healthcare because of fear of discrimination and worse general and mental health among transgender adults. These relationships remain significant even when controlling for provider noninclusivity, suggesting that fear of discrimination and consequent delay of care are at the forefront of health challenges for transgender adults. The lack of statistical significance for noninclusive healthcare may be related to the measurement approach used; future research is needed to develop an improved tool for measuring transgender noninclusive healthcare.

Individual, social and community-level predictors of wellbeing in a US sample of transgender and gender non-conforming individuals

In the last decade, increased attention has been paid to the physical and mental health needs of transgender and gender non-conforming individuals. However, despite this surge of research, scant literature addresses factors associated with wellbeing among members of this population. Using data from the US Social Justice Sexuality Survey, this study examines predictors of wellbeing in a sample of transgender and gender non-conforming individuals. Results indicate that higher levels of wellbeing are predicted by education, older age and a greater sense of connectedness to the lesbian, gay, bisexual and transgender community. Additionally, although health insurance did not have a significant impact on wellbeing, increased general health was associated with greater wellbeing, as was perceived comfort of the healthcare provider regarding the respondent's sexual identity. These findings can inform multi-level intervention with transgender and gender non-conforming persons to promote their wellbeing, as well as guide policies and practices around healthcare provider training. Future research should further examine the interconnected predictors of wellbeing among members of this population.

Transform Health Arkansas: A Transgender-Led Partnership Engaging Transgender/Non-Binary Arkansans in Defining Health Research Priorities

BACKGROUND

Transgender/non-binary (trans/NB) individuals face major challenges, including within health care.

OBJECTIVES

Transform Health Arkansas (THA) engaged trans/ NB Arkansans in defining their greatest health-related concerns to inform responsive, partnered, participatory research.

METHODS

The THA partnership engaged trans/NB individuals through an interactive, trans/NB-led process in nine summits across the state and collected surveys on research interests. Descriptive analysis examined respondent characteristics by gender identity, mode of survey completion, and most pressing concerns.

RESULTS

The summits, attended by 54 trans/NB and 29 cisgender individuals, received positive evaluations. The top five priorities among 140 survey respondents included (1) transition-related insurance coverage, (2) access to transition care, (3) education of health care providers, (4) public education, and (5) supportive health care systems. The THA has also led to trans/NB individuals educating a range of audiences about transgender issues.

CONCLUSIONS

Next steps include dissemination, identification of evidence-based interventions addressing prioritized issues, and joint development of a research agenda.

Barriers and facilitators to HIV and sexually transmitted infections testing for gay, bisexual, and other transgender men who have sex with men

Transgender men who have sex with men (trans MSM) may be at elevated risk for HIV and other sexually transmitted infections (STI), and therefore require access to HIV and STI testing services. However, trans people often face stigma, discrimination, and gaps in provider competence when attempting to access health care and may therefore postpone, avoid, or be refused care. In this context, quantitative data have indicated low access to, and uptake of, HIV testing among trans MSM. The present manuscript aimed to identify trans MSM's perspectives on barriers and facilitators to HIV and STI testing. As part of a community-based research project investigating HIV risk and resilience among trans MSM, 40 trans MSM aged 18 and above and living in Ontario, Canada participated in one-on-one qualitative interviews in 2013. Participants described a number of barriers to HIV and other STI testing. These included both trans-specific and general difficulties in accessing sexual health services, lack of trans health knowledge among testing providers, limited clinical capacity to meet STI testing needs, and a perceived gap between trans-inclusive policies and their implementation in practice. Two major facilitators were identified: access to trusted and flexible testing providers, and integration of testing with ongoing monitoring for hormone therapy. Based on these findings, we provide recommendations for enhancing access to HIV and STI testing for this key population.

Correlates of clinical breast examination among lesbian, gay, bisexual, and queer women

OBJECTIVES

Lesbian, gay, bisexual, and queer (LGBQ) women have increased risk of breast cancer yet lower use of early detection screening than heterosexual women. This lower use may be due in part to sexual stigma. The study purpose was to explore correlates of past two-year clinical breast examination (CBE) among LGBQ women to better understand screening disparities, particularly among gender non-conforming LGBQ women.

METHODS

A cross-sectional Internet-based survey was conducted with LGBQ women in 2011-2012. We conducted multivariate logistic regression to assess the associations between individual, social/structural and health care factors and past two-year CBE among LGBQ women (n = 414), including a subsample of gender non-conforming LGBQ women (n = 148).

RESULTS

In multivariate analyses, significant correlates of past two-year CBE among the full sample included sexually transmitted infection knowledge (OR: 1.12, 95% CI: 1.05, 1.19), sexual risk practices (OR: 0.92, 95% CI: 0.87, 0.98), past two-year Papanicolaou test (OR: 8.36, 95% CI: 4.24, 16.45), having a regular source of health care (OR: 4.84, 95% CI: 2.60, 9.01), and health care provider knowing one's sexual orientation (OR: 3.60, 95% CI: 2.29, 5.81). Among gender non-conforming LGBQ women, perceived gender non-conformity stigma (OR: 0.85, 95% CI: 0.74, 0.99) and belief that one's health care provider is uncomfortable with one's sexual orientation (OR: 0.33, 95% CI: 0.11, 1.00) were also associated with lower screening.

CONCLUSION

These findings enhance understanding of individual, social/structural, and health care factors correlated with CBE among LGBQ women. More research is needed to understand the complex interplay of these factors to inform multi-level interventions to address screening disparities for diverse LGBQ women.

High Willingness to Use HIV Pre-Exposure Prophylaxis Among Transgender Women in Argentina

Purpose: In Argentina, transgender women face a disproportionately high prevalence of HIV infection (34%). Although not currently approved in Argentina, pre-exposure prophylaxis (PrEP) may offer a potential effective HIV prevention tool for this population. In this study, we assessed the willingness to use PrEP among transgender women in Argentina. Methods: Data were drawn from a nationwide cross-sectional survey conducted among transgender women in 2013. Using multivariable logistic regression, we assessed the prevalence of and factors associated with willingness to use PrEP among transgender women with negative or unknown HIV status. Results: This study included 337 transgender women (278 HIV negative and 59 with unknown HIV status), most of whom had a history of sex work involvement (81.8%). Overall, 301 (89.3%) expressed willingness to use PrEP. In a multivariable analysis, having casual sexual partners was positively associated with willingness to use PrEP (adjusted odds ratio [AOR]=4.26, 95% confidence interval [CI] 1.73-10.51), while discrimination by healthcare workers was negatively associated (AOR=0.33, 95% CI 0.12-0.88). Conclusion: We found high levels of willingness to use PrEP among transgender women in Argentina, suggesting that there is high perception of HIV risk in this population. However, discrimination by healthcare workers was a strong negative correlate of willingness to use PrEP, suggesting that multilevel interventions that address gender-based stigma in healthcare settings will be critical for the success of PrEP as an HIV prevention strategy in this population.

Geographic and Individual Differences in Healthcare Access for U.S. Transgender Adults: A Multilevel Analysis

PURPOSE

To identify geographic and individual-level factors associated with healthcare access among transgender people in the United States.

METHODS

Multilevel analyses were conducted to investigate lifetime healthcare refusal using national data from 5831 U.S. transgender adults. Hierarchical generalized linear models examined associations between individual (age, gender, race, income, insurance, and healthcare avoidance) and state-level factors (percent voting Republican, percent same-sex couple households, income inequality, and transgender protective laws) and lifetime refusal of care.

RESULTS

Results show that individual-level factors (being older; trans feminine; Native American, multiracial, or other racial/ethnic minority; having low income; and avoiding care due to discrimination) are positively associated with care refusal (all P-values <0.05). Adjusting for individual-level factors, variation was observed across U.S. states, with a greater proportion of states in the Southern and Western United States with transgender residents at increased odds of experiencing care refusal, relative to other regions of the United States. When adjusting for state-level factors, the percentage of the state population voting Republican was positively associated with care refusal among the transgender adults sampled (P < 0.01).

CONCLUSION

Transgender adults surveyed reported differential access to healthcare by geographic region. Identifying geographic and individual-level factors associated with healthcare barriers allows for the development of targeted educational and policy interventions to improve healthcare access for transgender people most in need of services.

Health, disability and quality of life among trans people in Sweden-a web-based survey

Background

Swedish research concerning the general health of trans people is scarce. Despite the diversity of the group, most Swedish research has focused on gender dysphoric people seeking medical help for their gender incongruence, or on outcomes after medical gender-confirming interventions. This paper examines self-rated health, self-reported disability and quality of life among a diverse group of trans people including trans feminine, trans masculine, and gender nonbinary people (identifying with a gender in between male of female, or identify with neither of these genders) as well as people self-identifying as transvestites.

Methods

Participants were self-selected anonymously to a web-based survey conducted in 2014. Univariable and multivariable regression analyses were performed. Three backward selection regression models were conducted in order to identify significant variables for the outcomes self-rated health, self-reported disability and quality of life.

Results

Study participants included 796 individuals, between 15 and 94 years of age who live in Sweden. Respondents represented a heterogeneous group with regards to trans experience, with the majority being gender nonbinary (44 %), followed by trans masculine (24 %), trans feminine (19 %) and transvestites (14 %). A fifth of the respondents reported poor self-rated health, 53 % reported a disability and 44 % reported quality of life scores below the median cut-off value of 6 (out of 10). Nonbinary gender identity (adjusted Odds Ratio (aOR) = 2.19; 95 % CI: 1.24, 3.84), negative health care experiences (aOR = 1.92; 95 % CI: 1.26, 2.91) and not accessing legal gender recognition (aOR = 3.06; 95 % CI: 1.64, 5.72) were significant predictors for self-rated health. Being gender nonbinary (aOR = 2.18; 95 % CI: 1.35, 3.54) and history of negative health care experiences (aOR = 2.33; 95 % CI: 1.54, 3.52) were, in addition, associated with self-reported disability. Lastly, not accessing legal gender recognition (aOR = 0.32; 95 % CI: 0.17, 0.61) and history of negative health care experiences (aOR = 0.56; 95 % CI: 0.36, 0.88) were associated with lower quality of life.

Conclusions

The results of this study demonstrate that the general health of trans respondents is related to vulnerabilities that are unique for trans people in addition to other well-known health determinants.

Global health burden and needs of transgender populations: a review

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men

INTRODUCTION

Free or low-cost HIV testing, condoms, and lubricants are foundational HIV prevention strategies, yet are often inaccessible for men who have sex with men (MSM). In the global context of stigma and poor healthcare access, transgender (trans) MSM may face additional barriers to HIV prevention services. Drawing on data from a global survey of MSM, we aimed to describe perceived access to prevention services among trans MSM, examine associations between stigma and access, and compare access between trans MSM and cisgender (non-transgender) MSM.

METHODS

The 2014 Global Men's Health and Rights online survey was open to MSM (inclusive of trans MSM) from any country and available in seven languages. Baseline data (n=3857) were collected from July to October 2014. Among trans MSM, correlations were calculated between perceived service accessibility and anti-transgender violence, healthcare provider stigma, and discrimination. Using a nested matched-pair study design, trans MSM were matched 4:1 to cisgender MSM on age group, region, and HIV status, and conditional logistic regression models compared perceived access to prevention services by transgender status.

RESULTS

About 3.4% of respondents were trans men, of whom 69 were included in the present analysis. The average trans MSM participant was 26 to 35 years old (56.5%); lived in western Europe, North America, or Oceania (75.4%); and reported being HIV-negative (98.6%). HIV testing, condoms, and lubricants were accessible for 43.5, 53.6, and 26.1% of trans MSM, respectively. Ever having been arrested or convicted due to being trans and higher exposure to healthcare provider stigma in the past six months were associated with less access to some prevention services. Compared to matched cisgender controls, trans MSM reported significantly lower odds of perceived access to HIV testing (OR=0.57, 95% CI=0.33, 0.98) and condom-compatible lubricants (OR=0.54, 95% CI=0.30, 0.98).

CONCLUSIONS

This first look at access to HIV prevention services for trans MSM globally found that most reported inadequate access to basic prevention services and that they were less likely than cisgender MSM to have access to HIV testing and lubricants. Results indicate the need to enhance access to basic HIV prevention services for trans MSM, including MSM-specific services.

Mental health help seeking patterns and associations among Australian same sex attracted women, trans and gender diverse people: a survey-based study

BACKGROUND

Same sex attracted women (SSAW) are disproportionately affected by depression and anxiety, due to experiences of sexuality and gender based discrimination. They access mental health services at higher rates than heterosexual women, however with lower levels of satisfaction. This study examined the range of professional and social help seeking by same-sex attracted women, and patterns according to sexual orientation and gender identity subgroup.

METHODS

Eight key stakeholders were interviewed, and a convenience sample of 1628 Australian SSAW completed an online survey in 2015. This included several scales to measure mental health, community connectedness and resilience; and measured past 12 month help seeking behaviour, enablers, barriers and preferences for mental health care. Chi-square analyses and binary logistic regression analyses examined demographic associations with mental health. Correlations between help seeking, mental and physical health, and connectedness were run.

RESULTS

A high proportion (80 %) of the total sample had perceived mental health problems over the past 12 months. Over half had depression, and over 96 % had anxiety. Trans and gender diverse participants were twice as likely as female participants to have mental health problems, and lesbians were least likely. High levels of past 12 month help seeking included 74.4 % seeing a GP, 44.3 % seeing a psychologist/counsellor, 74.7 % seeking family/friends support and 55.2 % using internet based support. Professional help was prioritised by those with higher mental health need. Trans participants were most likely to have sought professional help and participated in support groups, but least likely to have sought help from friends or family. The most common barriers to help seeking were discrimination and lack of LGBTI sensitivity of services, particularly for gender diverse, queer and pansexual participants. Enablers included mainstream community connectedness, having a trustworthy GP, and encouragement by friends.

CONCLUSIONS

Mental health services need to be LGBTI inclusive and to understand the emerging diverse sexual and gender identities. Peer support is an important adjunct to professional support, however may not be fully meeting the needs of some identity sub-groups. Mental health promotion should be tailored for diverse sub-groups to build mental health literacy and resilience in the face of ongoing discrimination.

An Intersectional Perspective on Access to HIV-Related Healthcare for Transgender Women

Transgender women experience decreased access to HIV-related healthcare relative to cisgender people, in part due to pervasive transphobia in healthcare. This perspective describes intersectionality as a salient theoretical approach to understanding this disparity, moving beyond transphobia to explore how intersecting systems of oppression, including cisnormativity, sexism/transmisogyny, classism, racism, and HIV-related, gender nonconformity, substance use, and sex work stigma influence HIV-related healthcare access for transgender women living with HIV. This perspective concludes with a discussion of how intersectionality-informed studies can be enhanced through studying underexplored intersections and bringing attention to women's resiliency and empowerment.

Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions

RATIONALE

Transgender people in the United States experience widespread prejudice, discrimination, violence, and other forms of stigma.

OBJECTIVE

This critical review aims to integrate the literature on stigma towards transgender people in the U.S.

RESULTS

This review demonstrates that transgender stigma limits opportunities and access to resources in a number of critical domains (e.g., employment, healthcare), persistently affecting the physical and mental health of transgender people. The applied social ecological model employed here elucidates that transgender stigma operates at multiple levels (i.e., individual, interpersonal, structural) to impact health. Stigma prevention and coping interventions hold promise for reducing stigma and its adverse health-related effects in transgender populations.

CONCLUSION

Additional research is needed to document the causal relationship between stigma and adverse health as well as the mediators and moderators of stigma in US transgender populations. Multi-level interventions to prevent stigma towards transgender people are warranted.

Cervical Cancer Screening for Patients on the Female-to-Male Spectrum: a Narrative Review and Guide for Clinicians

Guidelines for cervical cancer screening have evolved rapidly over the last several years, with a trend toward longer intervals between screenings and an increasing number of screening options, such as Pap/HPV co-testing and HPV testing as a primary screening. However, gynecological recommendations often do not include clinical considerations specific to patients on the female-to-male (FTM) spectrum. Both patients and providers may not accurately assess risk for HPV and other sexually transmitted infections, understand barriers to care, or be aware of recommendations for cervical cancer screening and other appropriate sexual and reproductive health services for this patient population. We review the evidence and provide guidance on minimizing emotional discomfort before, during, and after a pelvic exam, minimizing physical discomfort during the exam, and making adaptations to account for testosterone-induced anatomical changes common among FTM patients.

Demographic and Psychosocial Factors Associated With Psychological Distress and Resilience Among Transgender Individuals

OBJECTIVES

We examined the independent demographic and psychosocial factors associated with psychological distress and resilience among transgender men and women.

METHODS

Our data came from an online survey involving a national Australian sample of 169 transgender men and women in 2011. Survey questions assessed demographics; sources of support; contact with lesbian, gay, bisexual, and transgender peers; and experiences of victimization. We assessed the outcomes with the Kessler Psychological Distress Scale and the Brief Resilience Scale.

RESULTS

In all, 46.0% of the sample reported high or very high levels of psychological distress. Multivariable regression analyses identified considerably different independent factors for psychological distress and resilience. Younger age, feeling unable to turn to family for support, and victimization experiences were associated with greater psychological distress, whereas higher income, identifying as heterosexual, and having frequent contact with lesbian, gay, bisexual, and transgender peers were associated with greater resilience.

CONCLUSIONS

With different factors identified for psychological distress and resilience, these findings may help inform the development of tailored mental health interventions and resilience-building programs for this vulnerable population.

The Social Costs of Gender Nonconformity for Transgender Adults: Implications for Discrimination and Health

Research suggests that transgender people face high levels of discrimination in society, which may contribute to their disproportionate risk for poor health. However, little is known about whether gender nonconformity, as a visible marker of one's stigmatized status as a transgender individual, heightens trans people's experiences with discrimination and, in turn, their health. Using data from the largest survey of transgender adults in the United States, the National Transgender Discrimination Survey (N = 4,115), we examine the associations among gender nonconformity, transphobic discrimination, and health-harming behaviors (i.e., attempted suicide, drug/alcohol abuse, and smoking). The results suggest that gender nonconforming trans people face more discrimination and, in turn, are more likely to engage in health-harming behaviors than trans people who are gender conforming. Our findings highlight the important role of gender nonconformity in the social experiences and well-being of transgender people.

Demographic and Psychosocial Factors Associated With Psychological Distress and Resilience Among Transgender Individuals

OBJECTIVES

We examined the independent demographic and psychosocial factors associated with psychological distress and resilience among transgender men and women.

METHODS

Our data came from an online survey involving a national Australian sample of 169 transgender men and women in 2011. Survey questions assessed demographics; sources of support; contact with lesbian, gay, bisexual, and transgender peers; and experiences of victimization. We assessed the outcomes with the Kessler Psychological Distress Scale and the Brief Resilience Scale.

RESULTS

In all, 46.0% of the sample reported high or very high levels of psychological distress. Multivariable regression analyses identified considerably different independent factors for psychological distress and resilience. Younger age, feeling unable to turn to family for support, and victimization experiences were associated with greater psychological distress, whereas higher income, identifying as heterosexual, and having frequent contact with lesbian, gay, bisexual, and transgender peers were associated with greater resilience.

CONCLUSIONS

With different factors identified for psychological distress and resilience, these findings may help inform the development of tailored mental health interventions and resilience-building programs for this vulnerable population.

Transgender and gender nonconforming adolescent care: psychosocial and medical considerations

PURPOSE OF REVIEW

Transgender individuals display incongruence between their assigned birth sex and their current gender identity, and may identify as male, female, or being elsewhere on the gender spectrum. Gender nonconformity describes an individual whose gender identity, role, or expression is not typical for individuals in a given assigned sex category. This update highlights recent literature pertaining to the psychosocial and medical care of transgender and gender nonconforming (TGN) adolescents with applications for the general practitioner.

RECENT FINDINGS

The psychological risks and outcomes of TGN adolescents are being more widely recognized. Moreover, there is increasing evidence that social and medical gender transition reduces gender dysphoria, defined as distress that accompanies the incongruence between one's birth sex and identified gender. Unfortunately, lack of education about TGN adolescents in medical training persists.

SUMMARY

Recent literature highlights increased health risks in TGN adolescents and improved outcomes following gender dysphoria treatment. It is important for clinicians to become familiar with the range of treatment options and referral resources available to TGN adolescents in order to provide optimal and welcoming care to all adolescents.

Differences Across Age Groups in Transgender and Gender Non-Conforming People’s Experiences of Health Care Discrimination, Harassment, and Victimization

Objective: Given the increasing diversity among older adults and changes in health policy, knowledge is needed on potential barriers to health care for transgender and gender non-conforming (GNC) individuals. Method: Using the 2010 National Transgender Discrimination Survey (NTDS), logistic regression models test differences between age groups (below 35, 35-49, 50-64, and 65 and above) in lifetime experience of anti-transgender discrimination, harassment, and victimization within health care settings while considering the influences of insurance status, level of passing, time of transition, and other socio-demographic factors. Results: Although more than one fifth of transgender and GNC individuals of all ages reported health discrimination, harassment, or victimization, significant age differences were found. Insurance status and level of passing were also influential. Discussion: Medicare policy changes and this study’s findings prompt further consideration for revising other health insurance policies. In addition, expanded cultural competency trainings that are specific to transgender and GNC individuals are crucial.

A Tale of Two Cities: Access to Care and Services Among African-American Transgender Women in Oakland and San Francisco

PURPOSE

The San Francisco Bay Area attracts people from all over the country due to the perception of lesbian, gay, bisexual, and transgender (LGBT) acceptance and affirmation. African-American transgender women are severely marginalized across society and as such have many unmet health and social service needs. This study sought to quantitatively assess unmet needs among African-American transgender women with a history of sex work by comparing residents of Oakland versus San Francisco.

METHODS

A total of 235 African-American transgender women were recruited from San Francisco (n=112) and Oakland (n=123) through community outreach and in collaboration with AIDS service organizations. Participants were surveyed regarding basic, health, and social needs and HIV risk behaviors. Pearson Chi-squared tests and a linear regression model examined associations between city of residence and unmet needs.

RESULTS

While participants from both cities reported unmet needs, Oakland participants had a greater number of unmet needs in receiving basic assistance, mental health treatment, and health care services. Oakland participants also reported less transgender community identification but higher social support from the family.

CONCLUSION

These findings demonstrate the enormity of African-American transgender women's needs within the Bay Area. Greater resources are needed for social service provision targeting this marginalized group of people, particularly in Oakland.

The aging population: imperative to uncouple sex and gender to establish "gender equal" health care

AIM

The transgender community has long been marginalized in society. As the world's population ages, gender-unbiased health services for this growing population, with age-related chronic illnesses, will be essential. To optimally eliminate hurdles that trans individuals often confront when requesting services, it appears judicious to eliminate the strict and antiquated definition of what constitutes "normal" female and "normal" male.

METHODS

A review of literature on transgender medicine on PubMed over the last five years was conducted.

RESULTS

Existing statistics indicate that unacceptable bias and discrimination are occurring, making trans patients less likely to seek care. There are emerging initiatives that address the transgender and gender non-conforming population. Ongoing needs include defining what constitutes "gender equal," understanding the continuum of gender identity, and establishing and implementing guidelines for gender equal counseling and care.

CONCLUSIONS

With the routine practice of defining sex at birth and equating sex with gender in the health care setting, the transgender patient encounters multiple barriers to accessing and acquiring health care services. These strict gender labels appear to preclude the institution of gender equal care. Care templates on gender equal patient encounters should be implemented to better address transgender health needs in a non-biased manner.

Factors associated with healthcare avoidance among transgender women in Argentina

Introduction

Transgender (TG) women in many settings continue to contend with barriers to healthcare, including experiences of stigma and discrimination. Argentina has a universal health care system and laws designed to promote healthcare access among TG women. However, little is known about barriers to healthcare access among TG women in this setting. The aim of this study was to explore individual, social-structural and environmental factors associated with healthcare avoidance among TG women in Argentina.

Methods

Data were derived from a 2013 nation-wide, cross-sectional study involving TG women in Argentina. We assessed the prevalence and factors associated with avoiding healthcare using multivariable logistic regression.

Results

Among 452 TG women included in the study, 184 (40.7%) reported that they avoided seeking healthcare because of their transgender identity. In multivariable analysis, factors positively associated with avoiding seeking healthcare were: having been exposed to police violence (adjusted odd ratio [aOR] = 2.20; 95% CI: 1.26 – 3.83), internalized stigma (aOR = 1.60, 95% CI: 1.02–2.51), having experienced discrimination by healthcare workers (aOR = 3.36: 95% CI: 1.25 – 5.70) or patients (aOR = 2.57; 95% CI: 1.58 – 4.17), and currently living in the Buenos Aires metropolitan area (aOR = 2.32; 95% CI: 1.44 – 3.76). In contrast, TG women with extended health insurance were less likely to report avoiding healthcare (aOR = 0.49; 95% CI: 0.26 – 0.93).

Conclusions

A high proportion of TG women in our sample reported avoiding healthcare. Avoiding healthcare was associated with stigma and discrimination in healthcare settings, as well as police violence experiences. Although further research is warranted, these finding suggests that socio-structural interventions tailored TG women needs are needed to improve access to healthcare among this population.

Towards full citizenship: correlates of engagement with the gender identity law among transwomen in Argentina

Introduction

In May 2012, Argentina passed its “Gender Identity” Law, which aimed to address the legal invisibility, discrimination and marginalization that transgender individuals have historically faced. The aim of this study was to explore factors associated with engagement with the Gender Identity Law among transwomen living in Argentina.

Methods

Data were derived from a 2013 nationwide, cross-sectional study involving transwomen in Argentina. Using multivariate logistic regression, we assessed the prevalence and factors associated with acquiring a gender-congruent identity card within the first 18 months of enactment of the Gender Identity Law.

Results

Among 452 transwomen, 260 (57.5%) reported that they had obtained a new gender-congruent identity card. In multivariate analysis, factors positively associated with acquiring a new ID were: previously experiencing discrimination by healthcare workers (adjusted odd ratio [aOR] = 2.01, 95% CI: 1.27–3.20); having engaged in transition procedures (aOR = 3.06, 95% CI: 1.58–5.93); and having a job other than sex work (aOR = 1.81, 95% CI: 1.06–3.10). Foreign born transwomen were less likely to have obtained a new ID (aOR = 0.14, 95% CI: 0.06–0.33).

Conclusions

More than half of transwomen in our sample acquired a new gender-congruent ID within the first 18 months of enactment of the Gender Identity Law. However, access to and uptake of this right has been heterogeneous. In particular, our findings suggest that the most empowered transwomen may have been among the first to take advantage of this right. Although educational level, housing conditions, HIV status and sex work were not associated with the outcome, foreign-born status was a strong negative correlate of new ID acquisition. Therefore, additional efforts should be made in order to ensure that benefits of this founding policy reach all transwomen in Argentina.