Supporting the Health of Transgender and Gender-Diverse Youth in Primary Care Settings

The experiences of transgender and nonbinary adults in primary care: A systematic review

BACKGROUND

Transgender and nonbinary (TNB) people face barriers to primary care, which remains the main entry point for accessing gender-affirming healthcare in the UK.

OBJECTIVES

This systematic review aims to summarise the evidence regarding TNB people's experiences of primary care to inform improvements in service and patient outcomes.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic literature search was conducted across articles from 2005 to April 2023 across Ovid Medline, Ovid Embase and PsychInfo using established keywords relating to gender identity, primary care and experiences. Qualitative data were thematically analysed and quantitative data were compiled using a descriptive narrative.

RESULTS

Following eligibility criteria, 16 articles were included in this review. This review identified both facilitators and limitations and barriers experienced by TNB people related to primary care provider knowledge; the patient-provider relationship, and healthcare settings. Quantitative findings reported up to 54.4% of participants were uncomfortable discussing TNB issues with their physician. Overall findings suggest TNB people face discrimination on a systemic level utilising primary care services, though positive healthcare encounters at a local level were reported. Participants expressed a desire for primary care-led gender-affirming healthcare services, with involvement from local TNB communities.

CONCLUSION

This review demonstrates TNB people's mixed experiences of primary care alongside their recommendations for service improvement. This is the first systematically reviewed evidence on the topic, emphasising the need for clinicians and policymakers to centre the voices of the TNB community in service design and improvement.

Pediatric Gender Care in Primary Care Settings in West Virginia: Provider Knowledge, Attitudes, and Educational Experiences

PURPOSE

Pediatric primary care providers (PPCPs) often care for gender diverse youth (GDY), particularly in rural areas, but little is known about their relevant knowledge, attitudes, or educational experiences regarding caring for this population.

METHODS

This study surveyed PPCPs throughout the rural state of West Virginia using an online survey assessing 1) demographics, 2) knowledge, 3) attitudes, and 4) educational experiences. Knowledge and attitude scores were calculated and proportion-tests and t-tests were used to compare these scores by PPCP characteristics including age, time in practice, and training background.

RESULTS

In total, 51 PPCPs from throughout the state completed the survey and 82% had cared for GDY in the prior year. Younger providers (

DISCUSSION

PPCPs in a rural state reported caring for GDY, but knowledge and attitudes related to this care varied by age, time in practice, and relevant educational experiences. More research is needed to determine best strategies for providing education to PPCPs, particularly those who are older and have been in practice longer, and to better understand the impacts of legislation limiting evidence-based gender-affirming care on PPCP knowledge, attitudes, and access to educational experiences.

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Key Words

• LGBTQ
• Pediatrics
• Primary care
• Rural health

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MESH Headings

• Humans
• West Virginia
• Female
• Male
• Health Knowledge, Attitudes, Practice
• Adult
• Primary Health Care
• Surveys and Questionnaires
• Attitude of Health Personnel
• Middle Aged
• Pediatrics/education
• Adolescent

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Grants

• U54 GM104942 NIGMS NIH HHS

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Affiliation(s)

Kacie M Kidd Division of Adolescent Medicine, Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia.
Alana Slekar West Virginia University, Morgantown, West Virginia
Gina M Sequeira Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Nicole F Kahn Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Lisa M Costello Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Isabela Negrin Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Sara Farjo WVU Urgent Care, West Virginia University School of Medicine, Morgantown, West Virginia
Savannah Lusk Department of Family Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
Snehalata Huzurbazar Department of Mathematics and Data Science, West Virginia University, Morgantown, West Virginia
Janani Narumanchi Department of Pediatrics, University of Tennessee School of Medicine, Memphis, Tennessee

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Shared care and gender identity support in Primary Care: The perspectives and experiences of parents/carers of young trans people

This article addresses the complex issues surrounding trans youths' shared care perceived by parents in primary care settings in the UK. The analyses in this article draws on qualitative data derived from an online survey of 153 parents with trans children. Through the conceptual framework of healthcare assemblages, findings suggest that quality shared care for trans youth is based upon transient service relationships inherent in their healthcare-primary care, gender identity services, endocrinologists, and Adolescent Mental Health Services (CAHMS)-and, as such, this complexity must be understood better by GPs in order for quality shared care to be administered. We explored various blockages to quality shared care within primary care surgeries that produced limit situations, such as lack of knowledge, training, or experience with trans healthcare. One other key factor was that there were strong external forces that were limiting trans youths' quality shared care in the form of abject depictions from beyond the consultation, which all produced negative effects. Despite these blockages, we also demonstrate how and where quality shared care is received. For instance, we show that continuity of care or treatment after an initial diagnosis or assessment contributes to quality shared care as too does personalized care to those youths receiving it. Overall, this research provides insights into the complex perceptions of parents about what quality shared care is and ought to be for trans youth.

Treatment Goals of Adolescents and Young Adults for Gender Dysphoria

OBJECTIVES

With this study, we aim to describe transgender and nonbinary adolescents and young adults' stated gender treatment goals at the time of initial presentation to medical care.

METHODS

This is a retrospective chart review of transgender and nonbinary patients aged 10 to 24 seeking specific gender-affirming health care. Charts were reviewed for specifically stated goals of future hormonal or surgical care for gender and analyzed by the experienced or asserted gender (man, woman, nonbinary, eclectic) of participants.

RESULTS

In total, 176 patient encounters were reviewed. Of these, 71% were assigned female at birth. Most participants experienced a masculine gender (46.6%), identified as white (65.3%), and had private health insurance (73.3%). Most patients had a goal of initiating hormone therapy (97.4%) and eventual surgery (87.1%). Of those who had a surgical goal, most (87.5%) desired surgery of the chest or breast, and a minority (29.3%) desired eventual genital surgery. The second-largest gender group was patients who either declined to state an asserted gender or felt unable to describe their gender experience (eclectic, 23.3%), and this group's treatment goals did not mirror any other group's goals.

CONCLUSIONS

At the time of initial presentation to medical care for gender-specific needs, many adolescents are capable of asserting specific treatment goals. Most do not desire genital surgery. A large minority of patients decline to state an asserted gender or feel unable to assert a specific gender, and this population appears distinct from more traditional genders in terms of treatment goals.

Strategies for Providing Gender-Affirming Care for Adolescents in the Primary Care Setting

Transgender and gender diverse (TGD) youth have high rates of health disparities and face significant barriers to accessing medical care. Primary care providers (PCPs) are often the first health care providers that TGD youth seek out to discuss gender identity and find support. Thus, it is crucial for PCPs to have an understanding of gender diversity and knowledge to support TGD youth with gender-affirming care. The purpose of this article is to offer strategies PCPs can implement to increase their comfort and capacity in providing care for TGD people. Key steps to support TGD youth in the primary care setting include creating affirming clinical environments, discussing gender identity at routine visits, supporting parents and families, supporting social transition, and providing menstrual suppression for those who desire it. Multidisciplinary gender clinics can partner with PCPs to support adolescents in accessing gender-affirming medical care and to provide additional education and support. [Pediatr Ann. 2023;52(12):e442-e449.].

Breaking the Binary: How Clinicians Can Ensure Everyone Receives High Quality Reproductive Health Services

The gender binary has historically defined the study and practice of reproductive and sexual healthcare. However, the male and female binary categorization of sex does not adequately define patients seeking reproductive and sexual health. Comprehensive sexual healthcare should consider diverse gender identity and non-heteronormative sexual practices, family planning, sexually transmitted infections, cancer prevention, and sexual function. Recent research suggests clinicians do not feel prepared to provide care for sexual and gender minority (SGM) patients. In this narrative review, we focus on reproductive and sexual health within the scope of obstetric and gynecologic (OB/GYN) clinical practice. We used traditional medical subject headings to summarize data from publications in peer-reviewed journals published in the last 10 years and identified barriers, facilitators and best practices for de-gendering reproductive healthcare. Following a roughly chronological care path across the lifespan, we categorized findings into the following topics: Early Care for SGM, Sexual Health, Family Planning, and Care Later in Life for SGM. We include recommendations for creating a welcoming environment, SGM inclusive training for clinicians and staff, and best practices for individualized counseling. We review suggested practices related to service delivery and clinical considerations in the provision of sexual and reproductive health care for gender and sexual minority patients.

Feasibility of communication platforms to empower transgender cultural competence among human immunodeficiency virus screeners: A qualitative analysis

Background

Human immunodeficiency virus (HIV) screeners have limited experience of interacting with trans people. The application of communication platforms between them to empower HIV screeners' trans-related cultural competence remains unknown.

Objective

This study aims to qualitatively explore the follow-up interviews of HIV screeners regarding their opinions on the feasibility of an online platform group discussion and web page to enhance communication between them and trans people and to explore their perspectives on how these components enhanced their promotion of cultural competence.

Methods

This study was conducted between October 2020 and June 2021. Purposive and snowball sampling were applied to recruit 6 trans persons and 11 HIV screeners. Six online platform group discussions were held on weekday evenings, each group meeting for 60 min, 360 min in total within 3 months, via a video chat room of Google Meet; this was supplemented by a closed web page. The major results were presented through content analysis of the HIV screeners' follow-up interviews.

Results

The HIV screeners identified the facilitators of participating in the communication platforms, which included a reminder message, easy-to-use interface, visible-audible and readable interaction, recalled and reviewable content and group belonging; the barriers included time and space limitation, device restrictions and operation problem. Two categories of trans-related cultural competence - trans awareness and action taken - were revealed, from which five major themes emerged: provoked to ask questions, improved cognition, reflection, trans-sensitive communication and self-enhancement.

Conclusion

The results revealed that the communication platforms could facilitate the mutual and vivid discussion between HIV screeners and trans people and empower the trans-related cultural competence of HIV screeners. The highly feasible intervention design of this research can be applied to digital training courses related to gender diversity issues.