Patient satisfaction with gender identity clinic services in the United Kingdom

Desired decision-making role and treatment satisfaction among trans people during medical transition: results from the ENIGI follow-up study

BACKGROUND

Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people's desired decision-making role within TRMI and factors that influence these desires.

AIMS

The study investigated trans people's desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment.

METHODS

Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care.

OUTCOMES

Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth.

RESULTS

The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery.

CLINICAL IMPLICATIONS

A desired decision-making role cannot be predicted based on the trans person's sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth.

STRENGTHS AND LIMITATIONS

This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth.

CONCLUSION

This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high.

Initial Clinical Needs Among Transgender and Non-binary Individuals in a Large, Urban Gender Health Program

BACKGROUND

Transgender and gender-diverse individuals are particularly vulnerable to healthcare discrimination and related health sequelae.

OBJECTIVE

To demonstrate diversity in demographics and explore variance in needs at the time of intake among patients seeking care at a large, urban gender health program.

DESIGN

We present summary statistics of patient demographics, medical histories, and gender-affirming care needs stratified by gender identity and sexual orientation.

PARTICIPANTS

We reviewed all intake interviews with individuals seeking care in our gender health program from 2017 to 2020.

MAIN MEASURES

Clients reported all the types of care in which they were interested at the time of intake as their "reason for call" (i.e., establish primary care, hormone management, surgical services, fertility services, behavioral health, or other health concerns).

KEY RESULTS

Of 836 patients analyzed, 350 identified as trans women, 263 as trans men, and 223 as non-binary. The most prevalent sexual identity was straight among trans women (34%) and trans men (38%), whereas most (69%) non-binary individuals identified as pansexual or queer; only 3% of non-binary individuals identified as straight. Over half of patients reported primary care, hormone management, or surgical services as the primary reason for contacting our program. Straight, transgender women were more likely to report surgical services as their primary reason for contacting our program, whereas gay transgender men were more likely to report primary care as their reason.

CONCLUSIONS

Individuals contacting our gender health program to establish care were diverse in sexual orientation and gender-affirming care needs. Care needs varied with both gender identity and sexual orientation, but primary care, hormone management, and surgical services were high priorities across groups. Providers of gender-affirming care should inquire about sexual orientation and detailed treatment priorities, as trans and gender-diverse populations are not uniform in their treatment needs or goals.

Community-based model for adolescent transgender health care

AIM

This study aimed to investigate whether transgender and non-binary (TGNB) youth prefer health care received in a community-based setting.

METHODS

All patients aged 12-18 years over a 1-year period presenting for transgender health care to either Tauranga Paediatrics, Maternal Infant Child and Adolescent Mental Health Services (MiCAMHS) or Gender Dynamix (a community-based TGNB health service) were invited to complete an anonymous online survey about their experience of health care. Responses were obtained from 39 participants (68.4% response rate).

RESULTS

Overall, patient responses indicated a preference for health care at Gender Dynamix. Adolescents preferred wait times (79%), as well as the physical environment (97%). Respondents felt less stigma in the community-based setting (68%). Information sharing and family and whanau support was high at both Gender Dynamix (94%; 86%) and Tauranga Paediatrics (86%; 86%), and low at MiCAMHS (33%; 32%). Patients were more likely to report being heard at Gender Dynamix (91%). Patients felt respected by staff (Gender Dynamix = 100%, Tauranga Paediatrics = 79% and MiCAMHS = 50%). All three services also had a high quality of health care (Gender Dynamix = 94%, Tauranga Paediatrics = 64% and MiCAMHS = 50%). For respondents who had seen a paediatrician in multiple locations, 100% of respondents preferred to be seen at Gender Dynamix (n = 13).

CONCLUSIONS

TGNB youth prefer to receive their health care in a community-based setting.

Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study

BACKGROUND

While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions.

AIM

To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics.

METHODS

As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis.

OUTCOMES

Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics.

RESULTS

Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care.

CLINICAL IMPLICATIONS

Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare.

STRENGTHS & LIMITATIONS

We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare.

CONCLUSION

These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail. IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921-1932.

Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people's accounts of navigating gender identity clinics

BACKGROUND

Transgender, or trans, people experience a number of barriers to accessing gender-affirming healthcare and have a range of barriers and facilitators to primary care and specialist services, commonly citing discrimination and cisgenderism playing a central role in shaping accessibility. The pathway through primary care to specialist services is a particularly precarious time for trans people, and misinformation and poorly applied protocols can have a detrimental impact on wellbeing.

METHOD

We recruited trans participants from an HIV Self-Testing Public Health Intervention (SELPHI) trial to interviews which explored contemporary gender-affirming service experiences, with an aim to examine the path from primary care services through to specialist gender services, in the UK.

RESULTS

A narrative synthesis of vignettes and thematic analysis of in-depth qualitative interviews were conducted with twenty trans individuals. We summarise positive and negative accounts of care under three broad categories: Experiences with primary care physicians, referrals to gender identity clinics (GICs), and experiences at GICs.

CONCLUSIONS

We discuss implications of this research in terms of how to improve best practice for trans people attempting to access gender-affirming healthcare in the UK. Here we highlight the importance of GP's access to knowledge around pathways and protocols and clinical practice which treats trans patients holistically.

Health Care Satisfaction in Relation to Gender Identity: Behavioral Risk Factor Surveillance Survey, 20 States (2014-2018)

BACKGROUND

Health care satisfaction is a key component of patient-centered care. Prior research on transgender populations has been based on convenience samples, and/or grouped all gender minorities into a single category.

OBJECTIVE

The objective of this study was to quantify differences in health care satisfaction among transgender men, transgender women, gender nonconforming, and cisgender adults in a diverse multistate sample.

RESEARCH DESIGN

Cross-sectional analysis of 2014-2018 Behavioral Risk Factor Surveillance System data from 20 states, using multivariable logistic models.

SUBJECTS

We identified 167,468 transgender men, transgender women, gender-nonconforming people, cisgender women, and cisgender men and compared past year health care satisfaction across these groups.

RESULTS

Transgender men and women had the highest prevalence of being "not at all satisfied" with the health care they received (14.6% and 8.6%, respectively), and gender-nonconforming people had the lowest prevalence of being "very satisfied" with their health care (55.7%). After adjustment for sociodemographic characteristics, transgender men were more likely to report being "not at all satisfied" with health care than cisgender men (odds ratio: 4.45, 95% confidence interval: 1.72-11.5) and cisgender women (odds ratio: 3.40, 95% confidence interval: 1.31-8.80).

CONCLUSIONS

Findings indicate that transgender and gender-nonconforming adults report considerably less health care satisfaction relative to their cisgender peers. Interventions to address factors driving these differences are needed.

Transgender women's satisfaction with healthcare services: A mixed-methods pilot study

BACKGROUND

Many transgender women are dissatisfied with healthcare services PURPOSE: (a) To describe satisfaction/dissatisfaction with healthcare services; and (b) to describe barriers/facilitators of satisfaction with healthcare services among a sample of transgender women.

DESIGN AND METHODS

A mixed methods design collected quantitative data (n = 50) and qualitative data (n = 25) from transgender women.

FINDINGS

Quantitatively, satisfaction with healthcare services was high among the participants, with lower areas related to healthcare systems issues. Qualitatively, participants identified barriers and facilitators of healthcare satisfaction.

IMPLICATIONS

This study provides clinical, research, educational, and policy implications for improving healthcare satisfaction among transgender women.

School-going transgender youths' experiences at health care facilities: a systematic scoping review protocol

BACKGROUND

Globally, miniscule improvements have been implemented regarding equality, inclusion, access, and protection of people with diverse gender identities whilst accessing health care facilities of which transgender youth form part. Literature has highlighted that the care transgender youth receive at health care facilities can result in positive or negative outcomes. School-going transgender youth constitute a unique group whose experiences at health care facilities warrant ongoing research. Hence, the objective of this scoping review is to systematically map evidence of school-going transgender youths' experiences at health care facilities regarding service delivery, support, and policies and to identify literature gaps that could inform future research.

METHODS

We will conduct a scoping review, using peer-reviewed journal articles that present literature on school-going transgender youths' experiences at health care facilities. Searches for relevant articles will be conducted on the following databases: PubMed, Cochrane Library, Campbell collaboration, Scopus, Embase, and MEDLINE. Additional searches will be conducted on institutional websites or web-based search portals. Two reviewers will independently extract data from all relevant search engines incorporating the study objective, research questions, and eligibility criteria. The inclusion criteria include published full-text qualitative, quantitative, and mixed-method studies that address the topic with no language and publication year limitations to reflect a comprehensive range of literature that includes the implementation of the SDGs. All literature that does not meet the inclusion criteria will be excluded. The quality of included studies will be appraised using the mixed methods appraisal tool (MMAT) - version 2018.

DISCUSSION

We anticipate mapping the experiences of school-going transgender youth at health care facilities. Once summarized, the data could be useful to clinical educators, health workers, policy makers, and guide future research to ensure that the human and patients' rights of transgender youth, are globally acknowledged, protected, and respected within health care facilities.

'Bye-bye boobies': normativity, deservingness and medicalisation in transgender medical crowdfunding

Transgender individuals experience multiple barriers to accessing care related to medical transition, including a shortage of providers as well as health insurance programmes that categorically exclude the provision of gender-affirming hormones and surgery. Like people seeking financial support for health care related to illness or injury, many transgender people utilise web-based crowdfunding to help pay for medical transition costs. Although a growing body of research finds that medical crowdfunding individualises the effects of health inequalities, little of this research has focused specifically on trans crowdfunding. A dataset of 410 crowdfunding campaigns for medical transition was created. The majority of online campaigns were used to fund chest surgeries among young, white, binary-identified trans men in the USA. On average, campaigns raise only about 25% of their fundraising goal. Using thematic narrative analysis, I find that campaign narratives exhibit several main themes: trans 101, biological essentialism, insurance access, deservingness, normative transition and notions of progress. These themes illustrate how transgender medical crowdfunding is a response to inequalities but also has the effect of reproducing them.

How Gender Identity and Treatment Progress Impact Decision-Making, Psychotherapy and Aftercare Desires of Trans Persons

The gender identity of trans individuals influences their treatment preferences, and this in turn seems to affect their individual treatment progress. However, there has been no research which—next to the impact of gender identity on treatment desires—has also investigated the influence of treatment progress using a measure which assumes various possible transition pathways of trans persons.Therefore, an online community survey of trans people was conducted in Germany in 2015. Data were collected via an online survey from a non-clinical sample of n = 415 trans individuals (over half assigned female at birth), aged 16–76 (Mean (M) = 38.12). Almost one fifth of participants embraced non-binary or genderqueer (NBGQ) identities. Participants progressed 60.77% (standard deviation (SD) = 35.21) through treatment at point of data collection, as measured by the individual treatment progress score (ITPS). All participants, especially participants assigned male at birth, differed significantly in desire to participate in decision-making processes based on transition progress; individuals without treatment experience had less desire to decide treatment plans. NBGQ participants assigned male at birth in early stages of transition had significantly more desire for psychotherapy during transition than participants of the same identity in later transition stages. All participants, especially binary participants, significantly differed in desire for aftercare based on transition progress; individuals without treatment experience indicated more desire for aftercare. Results indicate health professionals should expect changing treatment desires in trans individuals at various stages of transition, particularly at treatment start, and based on gender identity.

Patient and Parent Experiences of Care at a Pediatric Gender Service

Purpose: To explore experiences of care at the Royal Children's Hospital Gender Service (RCHGS).

Methods: A total of 114 parents and 52 patients of the RCHGS completed an experience of care survey.

Results: Most participants highly rated elements of the family-centered care and multidisciplinary team at RCHGS. The majority were satisfied with the RCHGS (parents: 88%, patients: 92%) and would recommend the service (parents: 95%, patients: 89%). Reductions in distress after participation in RCHGS were noted. Wait time was an area of dissatisfaction. Ideas for improvement concerned information giving, family support provision, and improving access to care.

Conclusion: This study affirms the multidisciplinary family-centered model used at RCHGS.

Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey

This study investigates the needs and concerns transgender (short: trans) individuals have concerning trans healthcare (THC) in interdisciplinary THC centres. Trans individuals' gender does not (fully/constantly) match their sex assigned at birth. To be able to live in their gender role and to prevent or minimise gender dysphoria, they might require a multidisciplinary set of transition related healthcare services. The current shift from the traditionally highly regulated, hierarchical and pathologising approach to THC towards a more patient-centred approach has highlighted the importance of trans patients' satisfaction with treatment processes and results. As the still influential regulations have a negative effect on patient satisfaction, and might also keep trans individuals from seeking transition related treatment, it is crucial to investigate what trans individuals, whether patients or not, need and fear regarding transition related healthcare. Against the backdrop of mixed reactions received from the local trans community regarding the foundation of the Interdisciplinary Transgender Healthcare Centre Hamburg (ITHCCH), Germany, this study seeks to determine what trans individuals need with respect to THC in order to guarantee for high quality service provision at the ITHCCH. To this end, an online questionnaire was developed. The researchers employed a participatory approach to questionnaire development by involving a working group consisting of local trans support group representatives and (THC) specialists (N = 4). The sample consisted of N = 415 trans-identified individuals aged between 16 and 76. Most of them were based in Germany. 85.2% (n = 382) reported experience with transition related healthcare and 72.5% (n = 301) had (additional) treatments planned. Analysis revealed a need for communication and feedback opportunities. Furthermore, during the treatment process, addressing individual needs was considered crucial by participants. They agreed moderately with concerns towards THC centres. 96.5% of participants would like high decision-making power concerning treatment-associated decisions. The results demonstrate the importance of patient-centred THC that takes patients' individual needs and realities into consideration and involves patients in decision-making processes.

Exploring Healthcare Experiences of Transgender Individuals

Purpose: It has been widely noted that existing healthcare systems do not always function effectively for the transgender population. Despite existing healthcare barriers, however, transgender individuals have been shown to have positive healthcare experiences. This study explored a cohort of transgender individuals who had positive healthcare experiences, and those who were involved in creating a positive healthcare experience for transgender individuals. Methods: A single case study was conducted, which included 10 interviews with transgender individuals, healthcare providers, and friends/family/significant others of transgender individuals. Data were analyzed through thematic analysis. Results: Seven key themes emerged within macro levels (large-scale system), meso levels (local/interpersonal), and micro levels (individual/internal) of healthcare system support. At a macro level, few system strengths were shown, with hope for change in the future. On a meso level, both external supports and informal networking emerged as key factors in positive healthcare experiences. At the micro level, self-navigation, characteristics for success, and personal strategy development were important for achieving positive experiences. Conclusion: Factors that contribute to positive healthcare experiences for transgender individuals were outlined in this study, showing that meso and micro level support compensate for large-scale healthcare system deficits.

Self-injury among trans individuals and matched controls: prevalence and associated factors

This study aims to determine the prevalence rate of current non-suicidal self-injury (NSSI) among trans individuals, in comparison with a control sample of non-trans adults. It also aims to compare those with current NSSI and those with no history of NSSI in terms of psychological well-being, self-esteem, body dissatisfaction, social support and demographic factors. Participants were 97 adults, diagnosed with transsexualism (ICD-10, F64.0), attending a national gender clinic in the United Kingdom, and a matched control group. Clinical participants were all engaged on the treatment pathway. Participants completed the following self-report measures: Self-Injury Questionnaire - Treatment Related (SIQ-TR), Symptom Checklist 90 Revised (SCL-90-R), Rosenberg Self-Esteem Scale (RSE), Hamburg Body Drawing Scale (HBDS) and Multidimensional Scale of Perceived Social Support (MSPSS). The results showed that the trans participants had a significantly higher prevalence of current NSSI behaviour than the non-trans group, with 19% currently engaging in NSSI. Current NSSI was also significantly more prevalent among trans men than trans women. Compared with both trans and non-trans participants with no history of NSSI, trans participants with current NSSI had significantly higher scores on SCL; significantly lower scores on RSE, HBDS and MSPSS; and were younger in age. The study concludes that trans men, specifically, are more at risk of NSSI than trans women and the general population, even when on the treatment pathway. Those who currently self-injure have greater psychopathology, lower body satisfaction, lower self-esteem, lower social support and tend to be younger, than those who do not engage in NSSI.

Systematic Review and Meta-Analysis of Prevalence Studies in Transsexualism

Background

Over the last 50 years, several studies have provided estimates of the prevalence of transsexualism. The variation in reported prevalence is considerable and may be explained by factors such as the methodology and diagnostic classification used and the year and country in which the studies took place. Taking these into consideration, this study aimed to critically and systematically review the available literature measuring the prevalence of transsexualism as well as performing a meta-analysis using the available data.

Methods

Databases were systematically searched and 1473 possible studies were identified. After initial scrutiny of the article titles and removal of those not relevant, 250 studies were selected for further appraisal. Of these, 211 were excluded after reading the abstracts and a further 18 after reading the full article. This resulted in 21 studies on which to perform a systematic review, with only 12 having sufficient data for meta-analysis. The primary data of the epidemiological studies were extracted as raw numbers. An aggregate effect size, weighted by sample size, was computed to provide an overall effect size across the studies. Risk ratios and 95% confidence intervals (CIs) were calculated. The relative weighted contribution of each study was also assessed.

Results

The overall meta-analytical prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men. Time analysis found an increase in reported prevalence over the last 50 years.

Conclusions

The overall prevalence of transsexualism reported in the literature is increasing. However, it is still very low and is mainly based on individuals attending clinical services and so does not provide an overall picture of prevalence in the general population. However, this study should be considered as a starting point and the field would benefit from more rigorous epidemiological studies acknowledging current changes in the classification system and including different locations worldwide.

Social support and psychological well-being in gender dysphoria: a comparison of patients with matched controls

INTRODUCTION

There is a paucity of research in the area of social support and psychological well-being among people with gender dysphoria.

AIMS

The present study aimed to investigate levels of social support among individuals with gender dysphoria compared with a matched control group. It also aimed to examine the relationship between social support and psychological well-being.

METHODS

Participants were 103 individuals diagnosed with gender dysphoria (according to ICD-10 criteria) attending a national gender identity clinic and an age- and gender-matched nonclinical control group recruited via social networking websites.

MAIN OUTCOME MEASURES

All participants completed measures of social support (Multidimensional Scale of Perceived Social Support, MSPSS), psychopathology (Symptom Checklist 90 Revised, SCL), quality of life (Short Form 36 version 2, SF), and life satisfaction (Personal Wellbeing Index, PWI).

RESULTS

Trans women reported significantly lower MSPSS total and MSPSS family scores compared with control women, although these differences in levels of social support were no longer significant when SCL depression was controlled for. No significant differences were found between trans men and any other group. MSPSS scores did not significantly predict SCL subscales but did predict both SF subscales and PWI total scores.

CONCLUSIONS

Trans women perceived themselves to be lacking social support. Given that social support is beneficial to quality of life and life satisfaction in those with gender dysphoria, this is of great concern. Though these findings have been derived from correlational results, extended research may highlight the value of clinicians helping trans women to seek out and maintain social support. Additionally, efforts could be made to educate and challenge attitudes of nontrans people towards those with gender dysphoria.