First Impressions Online: The Inclusion of Transgender and Gender Nonconforming Identities and Services in Mental Healthcare Providers' Online Materials in the USA

Discrimination experiences of transgender individuals in healthcare: an interview study on the perspective of health professionals specializing in the treatment of transgender individuals

BACKGROUND

Experiences of discrimination in healthcare lead to poorer mental and physical health for transgender individuals. There is evidence that trans-specialists, i.e. health professionals specializing in transgender care, are an important source of discrimination experienced by transgender individuals in healthcare. In this qualitative interview study, we explored the reasons for this possibly surprising finding by analyzing subjective views of trans-specialists on various issues related to discrimination of transgender individuals.

METHODS

We conducted 20 semi-structured, qualitative, exploratory interviews with healthcare professionals specializing in transgender care. Interview questions were developed based on an extensive literature analysis and results of previous research on the topic. The interviews were conducted online, were digitally recorded and transcribed. Data analysis was conducted using the methods of content analysis and thematic analysis.

RESULTS

The interviewees had great difficulty giving a consistent definition of the concept of gender identity. Most of them saw it as a self-determination of a transgender individual. Although herewith emphasizing the autonomy of transgender individuals, most trans-specialists felt that they had to be convinced of their patient's transsexuality to carry out treatment. Most trans-specialists reported having had doubts about whether some transgender individuals were suffering from gender incongruence or not. There was also ambiguity among interviewees about whether transsexuality is a mental illness.

CONCLUSIONS

We were able to identify specific topics that can cause discrimination experiences on the part of transgender individuals in their contact with trans-specialists. These include the vagueness of the construct of gender identity and the ambivalence between respect for the autonomy of transgender individuals and the validation of the diagnosis "transsexuality". Also, uncertainties regarding the classification of transsexuality as a mental illness can lead to experiences of discrimination. Furthermore, our results imply that trans-specialists might remember own discriminatory behavior less than it actually took place. Our results can contribute to the development of specific measures to avoid discrimination experiences of transgender individuals in contact with trans-specialists. These should include a reflection on one's own gender identity and training on mechanisms of discrimination.

Mental Health and Marginalization Stress in Transgender and Gender Diverse Adults: Differences between Urban and Non-Urban Experiences

Background

Transgender and gender diverse (TGD) individuals face high rates of psychological distress, including depression, anxiety, and suicide risk. Further, TGD individuals living outside of urban areas experience additional disparities compared to their urban counterparts. Minority stress theory states that minority stressors (termed marginalization stressors for this paper), such as experiences of discrimination and internalized transphobia, lead to psychological distress. The current study compared marginalization stressors across rural (population less than 2,500), urban cluster (population between 2,500 and 50,000), and urban (population greater than 50,000) samples and tested the degree to which these stressors account for differences across areas of residence.

Methods

Participants were 225 TGD individuals who completed an online survey that included measures of depression, anxiety, suicidal ideation marginalization stress, and protective factors.

Results

In the first model, mental health outcomes, marginalization stressors, and protective factors differed between areas. Urban cluster participants reported experiencing higher levels of depression, anxiety, and suicidal ideation and rural participants reported experiencing higher levels of depression suicidal ideation than urban participants. Both rural and urban cluster participants reported more experiences of several marginalization stressors. In the subsequent path model, indirect effects between area and marginalization stress variables were significant, but urban cluster participants still reported higher depression, anxiety, and suicidal ideation symptoms (p-values < .05).

Discussion

We demonstrate that marginalization stress processes appear to account for some of the differences between TGD individuals living in urban, rural, and urban cluster areas. The differences between areas largely persist, however, after controlling for marginalization stress, especially when comparing urban with urban cluster areas.

Previous mental health care and help-seeking experiences: Perspectives from sexual and gender minority survivors of near-fatal suicide attempts

Sexual and gender minority (SGM) populations face heightened risk of suicide compared to their heterosexual and cisgender counterparts, and a previous suicide attempt is among the strongest predictors of suicide mortality. Despite this increased risk, limited research has explored mental health help-seeking behavior and previous mental health care experiences of SGM individuals among the highest risk for suicide-individuals with a recent, near-fatal suicide attempt. This study presents thematic analysis results of interviews with 22 SGM individuals who reported at least one near-fatal suicide attempt in the past 18 months. Identified themes were (a) factors that affect help-seeking for SGM individuals with a recent, near-fatal suicide attempt, including previous mental health care experiences, support systems, and structural barriers and facilitators; (b) hospitalization is not a one-size fits all solution; and (c) recommendations for improving care for this population. Findings demonstrate that anti-SGM stigma may magnify existing barriers to mental health care across all socioecological levels. Notably, participants cited a fear of loss of autonomy from inpatient hospitalization and previous discriminatory experiences when seeking mental health care as hampering help-seeking. Given increased risk for suicide mortality, this patient population is a necessary stakeholder in suicide prevention and intervention development and policy discussions affecting mental health care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Often-Circuitous Path to Affirming Mental Health Care for Transgender and Gender-Diverse Adults

PURPOSE OF REVIEW

We describe recent research regarding access to affirming mental health services for transgender and gender-diverse (TGD) adults and explore new resources available for therapists to inform evidence-based practice with TGD clients.

RECENT FINDINGS

Barriers and facilitators at all socioecological levels impact TGD adults' mental health help-seeking. TGD adults often interface with mental health providers while accessing gender-affirming medical care, though new standards of care are likely to alter this typically common path to mental health services. Efforts to improve therapist education, such as therapy manuals, are increasingly available and a necessary step to increase the number of competent, affirming therapists. More work-both advocacy and research-is needed to fully expand accessible, affirming mental health services for TGD adults. Better understanding factors impacting different steps of the mental health help-seeking process and conducting randomized controlled trials of affirming mental health services are important next steps.

Transgender and gender diverse adults' self-reported mental health diagnoses, engagement in mental health services, and perceptions of therapists

OBJECTIVE

Transgender and gender diverse (TGD) people face various challenges when seeking therapy. Given this, we wanted to understand more about TGD people's perceptions of providers and how these compare to researcher ratings of providers on metrics of affirming practice.

METHOD

The sample included 158 TGD adults (M_age = 33.06); 57.6% were in therapy. Participants completed measures about mental health, resilience, and therapy. We systematically coded provider websites and intake forms.

RESULTS

Participants in therapy were older, had higher depression, and lower resilience than participants not in therapy. Non-binary/genderqueer participants rated providers as less knowledgeable compared to trans feminine participants. Overall, participants appeared satisfied (71.4% extremely satisfied) and viewed providers as at least moderately knowledgeable (89.1%). Provider coding revealed variation across the markers of affirmation; 66.04% identified a TGD-specialty and only 26.42% shared provider pronouns. Higher frequency of inclusivity (via coding) was related to higher ratings of provider knowledge and more of a focus on gender, however, there was not a significant association with satisfaction.

CONCLUSIONS

Providers who engaged in more affirming practices were more knowledgeable compared to those who engaged in fewer affirming practices. This may influence the content of therapy and whether clients feel comfortable discussing gender.

Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults

Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.

Future Directions in Mental Health Treatment with Stigmatized Youth

Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color and transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma - defined as laws/policies and norms/attitudes that hurt stigmatized people - have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research.

Bridging the Gap Between Practice Guidelines and the Therapy Room: Community-Derived Practice Adaptations for Psychological Services with Transgender and Gender Diverse Adults in the Central United States

Individuals who identify as transgender or gender diverse (TGD) are presenting at mental health clinicians' offices with increasing frequency. Many TGD clients are seeking care related to affirming their gender identity but also may present with anxiety, depression, trauma, substance abuse, or other problems for which a clinician may commonly provide services. Some clinicians may hesitate to accept TGD clients into their practice if they have little specialized training to work with this population in an affirming manner, especially in more underserved areas where a generalist practice is the norm. Numerous professional associations and experts have developed guidelines for affirmative behavioral health care for TGD people. However, what is needed are community informed recommendations to bridge from the official guidelines to clinicians' in-session activities. The Trans Collaborations Practice Adaptations for Psychological Interventions for Transgender and Gender Diverse Adults are derived from iterative interviews with TGD community members and affirming mental health clinicians in the Central United States. The 12 practice adaptations are intended to guide clinicians to adapt their usual treatment approach to be TGD affirming, especially in underserved and rural areas. The practice adaptations cover numerous aspects of practice including the office setting and paperwork, understanding gender identity and incorporating it into the case conceptualization, therapist's self-awareness, and referrals. The Trans Collaborations Practice Adaptations will help clinicians work confidently and competently with adult TGD clients, regardless of the presenting problem, to ensure TGD communities receive the best interventions for their behavioral health concerns.

Access to Mental Healthcare in the 21st Century: An Evolutionary Concept Analysis

BACKGROUND

One of the most important aspects of receiving medical care is access to that care. For people with mental illness who have greater healthcare needs and are at risk for poor health outcomes, reduced access to care constitutes a crisis. While the COVID-19 (coronavirus disease 2019) pandemic continues to affect the United States, specifying what it means to have access to mental healthcare is more critical than ever.

AIMS

The aims of this concept analysis are to review definitions and descriptions of access to mental healthcare in the literature and to synthesize the relevance of these findings to inform future research, theory development, policy, and practice.

METHODS

The concept of access to mental healthcare was analyzed using Rodgers's evolutionary concept analysis method. CINAHL, PsycINFO, and MEDLINE were queried for peer-reviewed articles about access to mental healthcare published from January 2010 to April 2020 (n = 72). Data were reviewed for concept antecedents, attributes, consequences, surrogate, and related terms.

RESULTS

Five models of access to mental healthcare were identified, with several antecedents and consequences: utilization, economic loss/gain, incarceration, and patient/provider satisfaction. Cross-sectional and predictive studies highlighted three interrelated attributes: clinical management, healthcare delivery, and connectedness.

CONCLUSIONS

The concept of access to mental healthcare is often used stagnantly across disciplines to create health policies, yet the concept is transformative. Future research requires up-to-date operational definitions of access to mental healthcare to target interdisciplinary approaches.

Educational preparedness to care for transgender and gender diverse adults: Perspectives of mental health professionals

Ensuring that mental health professionals are appropriately trained to provide affirming and sensitive care to transgender and gender diverse (TGD) adults is one mechanism that may reduce the marginalization sometimes experienced by TGD adults in mental health contexts. In this study, mental health professionals (n=142) completed an online survey documenting the sources and types of training received to provide TGD-sensitive care; and, shared a self-assessment of their comfort, competence, and ability to provide TGD-sensitive care. Findings revealed that the majority of the mental health professionals in the study (approximately 81%) received specific training to work with TGD clients from a variety of sources. These mental health professionals also self-reported high levels of comfort, competence, and ability to offer TGD-sensitive care which were statistically significantly associated with the number of hours of TGD-specific training they had received.

The Impact of Mental Health Care Provider Website Transgender and Nonbinary Affirmation on Site User Experience for Transgender/Nonbinary and Cisgender People

Transgender and gender nonbinary (TGNB) individuals use provider information, such as websites, to ascertain whether providers are affirming of TGNB identities. Yet, providers may be unsure about what level of affirmation is sufficient to be perceived as affirming and may be concerned that cisgender people may have negative reactions to website material that is TGNB affirming. The present study undertook a user experience (UX) investigation of TGNB and cisgender participants' UX of mental health provider websites. Participants (310 cisgender, 224 TGNB) were recruited online. Participants viewed one of five mock provider websites. Results of a multivariate analysis of covariance (MANCOVA) indicated that TGNB had more positive evaluations of the three more affirming sites, compared to the less affirming sites, along UX domains related to likelihood of going to that provider, Mental Health Help-Seeking Attitudes, positive emotional UX, and negative emotional UX. Regardless of gender identity, participants rated the three more affirming sites as more welcoming. The results support the use of TGNB affirmation in the UX of TGNB individuals viewing provider websites and further suggest that TGNB affirmation does not detract from the UX of cisgender people. Implications for affirming practice with TGNB populations are reviewed.

Transgender patients' perspectives on their cancer genetic counseling experiences

Transgender (trans) individuals face many forms of discrimination in accessing health care, including lack of provider knowledge and denial of services. Barriers specific to the cancer setting include limited availability of information concerning cancer management and its potential impact on gender affirmation therapies and minimal training for providers regarding inclusive practices for the trans population. The limited research about the experiences of cancer genetic counseling for trans patients has investigated exclusively the perspective of the provider, not the patient. This constructivist grounded theory study sought to fill this gap in the literature by interviewing trans individuals who had undergone cancer genetic counseling. Participants were recruited through social media platforms, LGBTQ+ advocacy and cancer support groups, and the National Society of Genetic Counselors' list serv. Six semi-structured interviews were conducted with participants focusing on their expectations and goals prior to the genetic counseling session, concerns during the session, and reflections on inclusive practices. Transcripts were coded and analyzed using a constant comparative approach and five themes emerged: (a) Anxiety for the consult, (b) Disruptions of familial relationships and emotional support systems, (c) Use of inclusive language during session, (d) Impact on gender affirmation journey, and (e) Lack of appropriate cancer risk information for trans patients. The results from this pilot study suggest that trans patients experience anticipatory anxiety before the genetic counseling appointment, particularly about the potential of a physical examination. They may be more likely to experience disrupted family relationships that impact access to family history information and support. Genetic counselors should utilize inclusive language both when referring to the patient and when discussing cancer risk. Finally, additional research is needed to provide more accurate cancer risk predictions for trans individuals.

The Impact of the 2016 Presidential Elections on Transgender and Gender Diverse People

BACKGROUND

With Trump's presidency came a rise in the oppression of transgender and gender diverse (TGD) people, as the nation witnessed a removal of protections for TGD people.

METHOD

We examined the daily experiences of 181 TGD individuals (ages 16-40, M age = 25.6) through their reflections about daily stressors over the course of 8 weeks (data collected fall 2015-summer 2017), some of which reflected shifts during the election period.

RESULTS

During 2016 presidential election, participants reported a rise in marginalization stress and the subsequent impact on safety, mental health, and well-being. There were three emergent themes: External Rejection and Stigma from Dominant Culture; Supporting the TGD Community; and Fear for the Self and Development of Proximal Stressors.

CONCLUSION

In line with marginalization stress theory, participants vocalized the progression from exterior stigmatization to proximal stressors and their heightened sense of vigilance and fear of the dominant culture.

Cisgenderism and transphobia in sexual health care and associations with testing for HIV and other sexually transmitted infections: Findings from the Australian Trans & Gender Diverse Sexual Health Survey

Transgender and gender diverse people have unique risks and needs in the context of sexual health, but little is known about sexual health care for this population. In 2018, a national, online survey of sexual health and well-being was conducted with trans and gender diverse people in Australia (n = 1,613). Data from this survey were analysed to describe uptake of sexual health care and experiences of interpersonal and structural cisgenderism and transphobia. Experiences of cisgenderism and transphobia in sexual health care were assessed using a new, four-item scale of 'gender insensitivity', which produced scores ranging from 0 (highly gender sensitive) to 4 (highly gender insensitive). Logistic and linear regression analyses were conducted to determine if experiences of gender insensitivity in sexual health care were associated with uptake and frequency of HIV/STI testing in the 12 months prior to participation. Trans and gender diverse participants primarily accessed sexual health care from general practice clinics (86.8%), followed by publicly funded sexual health clinics (45.6%), community-based services (22.3%), and general hospitals (14.9%). Experiences of gender insensitivity were common overall (73.2% of participants reported ≥2 negative experiences) but most common in hospitals (M = 2.9, SD = 1.3) and least common in community-based services (M = 1.3, SD = 1.4; p<0.001). When controlling for sociodemographic factors, social networks, general access to health care, and sexual practices, higher levels of gender insensitivity in previous sexual health care encounters were associated with a lower likelihood of recent HIV/STI testing (adjusted prevalence ratio = 0.92, 95% confidence interval [CI]:091,0.96, p<0.001) and less-frequent HIV/STI testing (B = -0.07, 95%CI:-0.10,-0.03, p = 0.007). Given the high rates of HIV and other STIs among trans and gender diverse people in Australia and overseas, eliminating cisgenderism and transphobia in sexual health care may help improve access to diagnostic testing to reduce infection rates and support the overall sexual health and well-being of these populations.

Specialists in Name or Practice? The Inclusion of Transgender and Gender Diverse Identities in Online Materials of Gender Specialists

Recommendations for health care providers working with transgender and gender diverse (TGD) individuals emphasize affirming clients' identities, such as using correct pronouns and name, however it is unknown how often gender specialists adhere to such recommendations. Websites and intake forms of gender specialists were coded for use of affirming language, asking for pronouns and chosen name, and mention of TGD specialties and resources. Most websites identified the provider's specialty to work with TGD individuals, though much fewer provided additional resources concerning TGD issues and only half of intake forms included affirming language. Given previous research that has demonstrated providers working in states with legal protections for TGD individuals use affirming language more often than providers in locales without protections, association with state legal climate is also examined.

Common barriers to healthcare for transgender people in the U.S. Southeast

Background: Transgender and non-binary people are more likely to face barriers to healthcare than their cisgender counterparts. The majority of work in this area centers on the experiences of transgender people in northern cities and urban enclaves, yet over 500,000 transgender people live in the U.S. Southeast. Aims: The purpose of this study is to explore barriers to healthcare among transgender people in the U.S. Southeast. Methods: The research team conducted four 120-minute focus groups (eligibility criteria: 18 years or older, self-identify as transgender, live in the U.S. Southeast). Participants completed a demographic questionnaire prior to the start of the focus group. Each focus group explored access to and experiences of receiving basic healthcare as a transgender person in the U.S. Southeast. Established qualitative methods were used to conduct the focus groups and data analysis. Results: Participants (n = 48) ranged in age from 19 to 65, with the majority identifying as trans women (43.8%) and non-binary (33.3%). The sample was racially diverse: White (50%), Black (37.5%), and Latinx or Multiracial (12.5%). Multiple barriers to care were identified: (1) fear and mistrust of providers; (2) inconsistency in access to healthcare; (3) disrespect from providers; and, (4) mistreatment due to intersecting experiences of gender, race, class, and location. Discussion: Transgender Southerners face barriers to care at the structural, cultural, and interpersonal levels. The study results have implications for researchers, as well as providers, practices, and health care systems throughout the region.

Trans Collaborations Clinical Check-In (TC3): Initial Validation of a Clinical Measure for Transgender and Gender Diverse Adults Receiving Psychological Services

One key aspect of evidence-based psychological services is monitoring progress to inform treatment decision making, often using a brief self-report measure. However, no such measure exists to support measurement-based care, given the distinct needs of transgender and gender diverse people (TGD), a group facing large documented health disparities and marginalization in health care. The purpose of the present study was to develop and provide initial psychometric validation of a short, behavioral health progress monitoring self-report measure, the Trans Collaborations Clinical Check-in (TC3). TGD communities, providers identified as TGD-affirmative, and relevant academic experts contributed to item and scale development. The final 18-item version was administered to 215 TGD adults (75 transfeminine, 76 transmasculine, 46 nonbinary, 18 unknown; mean age of 30 with a range of 19 to 73), who were recruited for an online study, with other questionnaires assessing negative affect, well-being, gender dysphoria, gender minority stressors, and resilience. Higher scores on the TC3 (indicating better adjustment and comfort with gender) were generally associated with lower depression, anxiety, minority stress, and gender dysphoria and greater life satisfaction, body congruence, and positive aspects of being TGD such as pride in identity and community belongingness. These results support the validity of the TC3 as a brief measure to be used as a clinical tool for TGD people receiving mental health services. Additional research is needed on the reliability and validity of the TC3 across multiple time points to determine utility as a progress monitoring measure. The TC3 should also be further validated with more culturally diverse samples.

The provider perspective on behavioral health care for transgender and gender nonconforming individuals in the Central Great Plains: A qualitative study of approaches and needs

Transgender and gender nonconforming (TGNC) individuals interact with mental health care systems at high rates and experience substantial barriers to care. Rural TGNC individuals face additional disparities in accessing appropriate mental health services. Little research has focused on the mental health care providers who work with TGNC individuals in underserved areas. The current study sought to describe the mental health care services delivered by providers perceived as affirming by TGNC community members in the Central Great Plains. We conducted qualitative interviews with 10 providers to understand how providers seek cultural competency and conceptualize and work with their TGNC clients given the barriers to care. Providers held diverse theoretical orientations and described challenges to working with TGNC clients, including the impact of stigma and marginalization and financial and structural barriers to care. Emphasis was placed on individualizing care, helping clients to manage stigma and build resiliency, connecting clients to resources (when available) and support systems, and navigating the intersections of physical health care and mental health care, such as writing letters for medical transition. Providers largely educated themselves on TGNC topics and had previous experience working with marginalized populations. Overall, the providers' approaches to working with TGNC clients mapped onto models of cultural competency, but few providers described their work in the context of an evidence-based model. Implications for increasing the quality and availability of mental health care services for TGNC individuals in underserved areas are discussed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).