Providing gender-affirming hormone therapy through primary care: service users

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.

Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand

BACKGROUND

Past studies have demonstrated better mental health and well-being among transgender youth who had accessed gender-affirming care. However, few existing studies have assessed unmet need for gender-affirming care as a social determinant of mental health inequities.

METHODS

Data on unmet need for gender-affirming care, distress and suicidality were analysed from the 2018 Counting Ourselves nationwide community-based survey of transgender people in Aotearoa/New Zealand. Associations between unmet need for gender-affirming care and mental health indicators were tested for transgender youth within the sample (aged 14-26 years; n = 608; Mage = 20.5).

RESULTS

Transgender youth reported unmet needs ranging from 42% for gender-affirming hormone to 100% for feminizing surgeries and voice surgeries. Overall unmet need for gender-affirming care was associated with worse mental health. Trans men with an unmet need for chest reconstruction (84%) scored an average of 7.13 points higher on the K10 Psychological Distress Scale relative to those whose need had been met. Participants reporting unmet need for hormones (42%) had twice the odds (adjusted odds ratios = 2.01; CI = 1.02-3.98) of having attempted suicide in the last 12 months.

CONCLUSIONS

Dismantling barriers to accessing gender-affirming care could play a crucial role in reducing mental health inequities faced by transgender youth.

Characteristics and gender affirming healthcare needs of transgender and non-binary students starting hormone therapy in a student health service in Aotearoa New Zealand

Introduction Traditionally, gender-affirming hormonal therapy (GAHT) is initiated in secondary care, but a primary care based approach has been developed to reduce access barriers. Aim We aim to describe the demographics, hormone choices, and additional referrals made for young people initiating GAHT in a primary care setting in Aotearoa New Zealand. Methods Clinical notes were reviewed for all patients who commenced GAHT between 1 July 2020 to the end of 2022 at a tertiary education health service. Data were collected on age, ethnicity, gender, type of hormones prescribed, and any additional referrals. Results Eighty five patients commenced GAHT during the review period (64% assigned male at birth and starting oestrogen-based GAHT, 36% assigned female at birth and commencing testosterone-based GAHT). Fourty seven percent of patients identified as transgender female, 38% as non-binary, and 15% as transgender male. Spironolactone was the most common choice of testosterone blocker (81%). The choice of oestrogen formulation was fairly equal between patches (54%) and tablets (46%). Eighty percent of those assigned male at birth chose to preserve fertility, 54% requested voice therapy, and 87% of those assigned female at birth requested top surgery. Discussion There is a need for improved understanding of non-binary gender-affirmation needs, in particular those of Māori and Pasifika youth. An informed consent approach in primary care can reduce barriers and distress for transgender youth seeking GAHT. The high unmet need for top surgery for transgender people assigned female at birth requires attention.

Factors Associated with Experiences of Gender-Affirming Health Care: A Systematic Review

Purpose

Transgender people often pursue gender-affirming health care (GAH), such as hormone therapy and/or surgeries. While research has begun to explore influences on general health care for transgender individuals, less is known about the experiences of GAH specifically. We aimed to systematically review the factors associated with experiences of GAH.

Methods

PubMed, EMBASE, PsycInfo, and Web of Science were systematically searched for relevant literature using a predetermined search strategy. Studies were screened by two researchers to determine whether they fit the inclusion criteria. Following quality appraisal and data extraction, results were thematically analyzed.

Results

Thirty-eight studies were included in the review. Factors associated with experiences of GAH were broadly categorized as follows: (i) sociodemographic factors, (ii) treatment-related factors, (iii) psychosocial factors, and (iv) health care interactions, with health care interactions, in particular, being strong determinants of experience.

Conclusion

Findings suggest that experiences of GAH may be determined by a number of diverse factors, which have implications for understanding how to better support those undergoing transition. In particular, health care professionals play a key role in determining how transgender people experience treatment, which should be considered when providing care for this population.

Access to fertility preservation for trans and non-binary people in Aotearoa New Zealand

There is a growing need for healthcare professionals to discuss fertility preservation options with trans and non-binary people before commencing medical transition as part of informed consent-based models of care. In this article, we adapt the Five-A framework of healthcare access to examine fertility preservation information and services. To do so, we present an analysis of data from Counting Ourselves, the first comprehensive national survey in Aotearoa New Zealand of trans and non-binary people's health and the first study exploring their access to cryopreservation information and services. Among 419 participants who had received gender-affirming hormones or surgery, 33.7% received information about options for fertility preservation and 15.8% accessed fertility preservation services. Findings from the study indicate the need for greater understanding of trans and non-binary people's desire for genetically related children, and what type of information and form of delivery would be most helpful to ensure equitable outcomes in relation to decision-making around fertility and future family-building.

“Being Trans Intersects with My Cultural Identity”: Social Determinants of Mental Health Among Asian Transgender People

Purpose

While studies on the relationship between social determinants and mental health among transgender people in Asia are increasing, there is a paucity of research on Asian transgender people living in Western countries. This study aimed to examine how social positions (gender, ethnicity, and migrant status) and social determinants of mental health were inter-related for Asian transgender people in Aotearoa/New Zealand.

Methods

We analyzed both quantitative and qualitative data from Asian participants (n=49) who responded to the 2018 Counting Ourselves: Aotearoa New Zealand Trans and Non-Binary Health Survey.

Results

Overall, 35% reported a very high psychological distress level. There were high levels of unmet needs for gender-affirming care, and participants reported a range of negative experiences at health care settings. About two-fifths had been discriminated because of their transgender (42%) or Asian (39%) identities. Fewer than half of participants felt that their family members were supportive of them being transgender (44%), and most reported they had supportive friends (73%). More than two-thirds of participants (68%) had a strong sense of belongingness to the transgender community and 35% reported this for the Asian community. Qualitative findings revealed specific challenges that participants experienced; these included barriers to accessing health care due to their migrant status and language barriers, influences of Asian cultures on mental health experiences, and rejection by family and people in Asian communities.

Conclusion

Our study provides evidence for health care providers, researchers, and policy makers to employ a culturally appropriate lens to improve knowledge about the intersectional experiences of being Asian and transgender.

A community-based initiative to improve transgender mental health in Canterbury, New Zealand

Background and context The transgender community experiences high levels of mental distress. In the Canterbury region of New Zealand, transgender care was fragmented and there were gaps in service provision. Assessment of problem In 2019, a working group co-designed a model to coordinate and improve health care for the Canterbury transgender community. Their aim was to co-design and implement a comprehensive system for transgender health care that filled any existing gaps. Results A need was identified for support in the community for transgender patients with mild to moderate mental health needs who did not meet the threshold for referral to secondary care. Strategies for improvement Psychological packages of care were put in place in the community for transgender patients with mental health needs. In the first 9 months of the initiative, 85 patients received a package of care. Lessons This community-based model was well received by the community. Data analysis did not demonstrate a statistically significant reduction in depression and anxiety, but it did show a significant reduction in stress. Some further improvement opportunities existed, including shifting to a peer worker model and changing the evaluation tool.

Establishing a province-wide referral network to improve access to gender-affirming primary healthcare services

ABSTRACT

It is possible and necessary to provide trans and gender nonconforming (TGNC) individuals with gender-affirming care (GAC) in primary care settings. A known risk of increased suicidality among TGNC individuals and a lack of provider training on prescribing gender-affirming hormones (GAH) in the Canadian province of Nova Scotia highlighted a need for building capacity around GAC delivery. A referral network was established across the province, which reduced wait times to access GAH by several months.

"What if I'm not trans enough? What if I'm not man enough?": Transgender young adults' experiences of gender-affirming healthcare readiness assessments in Aotearoa New Zealand

Background

A growing body of transgender health research reports that transgender people often feel pressure to conform to a dominant narrative during gender-affirming readiness assessments. In New Zealand, however, no study to date has specifically examined transgender people's experiences of readiness assessments for gender-affirming healthcare.

Aims

This study aimed to explore the experiences of transgender young adults (aged 16-30) during gender-affirming readiness assessments in New Zealand. We also sought participants' views on improving transgender healthcare provision.

Methods

Thirteen transgender young adults took part in individual interviews or focus groups. Participants were asked to describe how they felt about the questions asked during readiness assessments and how the readiness assessment process could be improved. We used thematic analysis to identify patterns of meaning across the dataset.

Results

We identified two themes. Firstly, proving gender explores participants' views of readiness assessments as designed to establish whether they were "trans enough" or "truly" transgender, and why readiness assessments are conducted in this manner. Secondly, the trans narrative describes the pressure participants felt to adhere to a dominant transgender narrative in order to gain access to the healthcare they needed.

Discussion

Our findings call attention to the importance of a trans-affirmative approach and the need to clarify the purpose of gender-affirming healthcare readiness assessments in New Zealand.

'A little bubble of utopia': constructions of a primary care-based pilot clinic providing gender affirming hormone therapy

The provision of gender affirming hormone therapy for transgender and non-binary people is a rapidly developing area of gender affirming healthcare. While research indicates the benefits of providing gender affirming hormone therapy through interdisciplinary primary care-based models, less is known about how service users and providers construct their understandings of affirmative approaches. In this paper, we present findings from a discourse analysis of four service users' and four healthcare professionals' talk about a primary care-based pilot clinic providing gender affirming hormone therapy in Aotearoa New Zealand. Participants employed notions of pathologisation, time, and agency in their talk to construct the clinic as a personal setting which gave service users time to make their own health decisions, while constructing hospitals as impersonal with lengthy wait times. The assessment-driven nature of best practice guidelines that governed clinicians' decision-making was constructed as constraining users' agency. Findings highlight the ongoing importance of aligning gender affirming hormone therapy with other non-disease types of healthcare, and suggest new ways for achieving this through affirmative approaches to healthcare.