The experiences of transgender and non-binary children and young people and their parents in healthcare settings in England, UK: Interviews with members of a family support group

Provision of gender affirming care among medical and allied health practitioners: The influence of transnormative beliefs in working with gender diverse patients

Gender diverse patients (including gender diverse, transgender, and non-binary people) deserve quality health care, which has been referred to as gender affirming care. Given that practitioners' attitudes and competence can influence their provision of gender affirming care, this study used a lens of transnormativity (Bradford & Syed, 2019; Johnson, 2016) to develop a measure of practitioners' transnormative beliefs. The aim of the study was to determine if these beliefs were related to practitioners' gender affirming attitudes and perceptions of competence in gender affirming practice. Survey data were collected from Australian medical and allied health practitioners (N = 95). Exploratory factor analysis was applied to items measuring transnormative beliefs, with the results supporting three higher order factors; conditional approval, narrative, and gender role beliefs. Conditional approval reflected belief in gender diverse identity as authentic and worthy of intervention. Narrative beliefs reflected understanding of common developmental experiences among gender diverse populations, specifically experiences of victimisation and nascence. Gender role beliefs reflected belief in the existence of gender roles. In models that regressed gender affirming attitudes and self-perceived competency on all transnormative beliefs, controlling for demographics and work history, practitioners higher in conditional approval were lower in gender affirming attitudes and practitioners higher in narrative beliefs were higher in gender affirming attitudes and competency. Conditional approval was not significantly associated with competency, and gender role beliefs were not significantly associated with attitudes or competency. Results indicate that practitioners' transnormative beliefs are related to their gender affirming attitudes and suggest that targeting these beliefs through training opportunities could bridge the gap between gender diverse people's healthcare needs and the ability of healthcare practitioners to provide high quality care.

Delivering transgender-specific knowledge and skills into health and allied health studies and training: a systematic review

Many transgender individuals face inequities, discrimination, and sometimes even a lack of transgender-specific knowledge in health care settings. Educational curricula can address such disparities and help future health professionals to become more knowledgeable, confident, and well-prepared for addressing the needs of transgender individuals. This systematic review aims to summarize current training interventions about care of transgender individuals for health and allied health students, and to analyse the effects of the respective intervention. A total of six databases (Pubmed, MEDLINE, Scopus, Web of Science, Embase and SciSearch) were screened for original articles published between 2017 and June 2021. Search terms and eligibility criteria were pre-specified, and after a structured selection process 21 studies were included into further analysis. Extracted data contained information on general study properties, population, design, program format and outcomes of interest. A narrative synthesis was used to summarize detected results. Study quality was assessed for each individual study. A self-developed 18-item checklist combining criteria of two prior published tools was used to assess overall quality of quantitative studies. For qualitative studies a 10-item checklist by Kmet et al. [HTA Initiat, 2004] was applied. Eligible studies were designed for multiple health or allied health profession students, and varied widely regarding program format, duration, content, and assessed outcomes. Almost all (N = 19) interventions indicated improvements in knowledge, attitude, confidence and comfort levels or practical skills concerning care for transgender clients. Major limitations included the lack of long-term data, validated assessment tools, control groups and comparative studies. Training interventions contribute to prepare future health professionals to deliver competent and sensitive care and which may improve the prospective experienced health care reality of transgender individuals. However, currently there is no common consensus about best practice of education. Additionally, little is known about whether detected effects of training interventions translate into noticeable improvements for transgender clients. Further studies are warranted to assess the direct impact of specific interventions in the light of the respective target populations.

Family Discordance in Gender Identification Is Not Associated with Increased Depression and Anxiety Among Trans Youth

Purpose: We examined the relationship between parent- and child-reported gender identity of the youth with internalizing symptoms in transgender and gender-diverse (TGD) youth. In addition, we investigated differences in sex assigned at birth ratios and pubertal development stages in TGD and cisgender youth. Methods: We analyzed longitudinal data from the Adolescent Brain Cognitive Development study (ABCD), corresponding to baseline and 1st-to-3rd-year follow-up interviews (n = 6030 to n = 9743, age range [9-13]). Sociodemographic variables, self- and parent-reported gender identity, and clinical measures were collected. Results: TGD youth showed higher levels of internalizing symptoms compared with cisgender youth. However, this was not worsened by discordance in gender identification between TGD youth and parents. Over the 3-year follow-up period, the proportion of TGD participants increased from 0.8% (95% confidence interval (CI) [0.6-1.0]) at baseline to 1.4% (95% CI [1.1-1.7]) at the 3rd-year follow-up (χ2 = 10.476, df = 1, false discovery rate (FDR)-adjusted p = 0.00256), particularly among those assigned female at birth (AFAB) in relation to people assigned male at birth (AMAB) (AMAB:AFAB at baseline: 1:1.9 vs. AMAB:AFAB at 3rd-year follow-up: 1:4.7, χ2 = 40.357, df = 1, FDR-adjusted p < 0.0001). Conclusions: TGD youth in ABCD reported higher internalizing symptoms than cisgender youth, although this was not affected by parental discordance in gender identification. A substantial increase over time in TGD children AFAB was documented. More research is needed to understand the clinical implications of these preliminary results, for which the longitudinal design of ABCD will be crucial.

Erasure of the young trans person: A critical discursive review of contemporary health care literature

INTRODUCTION

Trans youth experience significantly higher rates of societal violence and ill-health compared to their cisgender peers. Although recent clinical guidelines for trans young people in health have paved the way for revolutionizing care, many trans young people still experience adversity in clinical settings. This discursive literature review provides a novel approach in exploring why trans young people experience violence in health care despite the availability of evidence-based resources and guidelines.

DESIGN

Databases (CINAHL and Scopus) were systematically searched to identify qualitative literature on the experiences of trans young people (<18 years) in health care settings.

METHOD

Rather than synthesizing and presenting the literature, Fairclough's (2001) CDA methodology was used to critically analyze the literature as texts in a data corpus. The authors engaged with the data from a critical social theory perspective.

RESULTS

Fifteen qualitative articles and one report (n = 16) on the experiences of trans young people (3-24 years) in health care settings were included. Two key discourses were identified in the literature. First, discourses that constituted the trans young person were identified in the definitions of 'trans' as a pathological incongruence and as alternate, self-determined ways of being. Further discourses were identified in the constitution of trans young people as victims, extra-pathological, and alternatively problematised as socially dysphoric. Second, discourses in health provider responses were identified in dismissive, gatekeeping, regulatory, and respectful practices.

DISCUSSION

The discursive constitution of the trans young person as incongruent, vulnerable, and pathological is constituted and generated by dismissive, gatekeeping, and regulatory practices of health care providers. The analysis reveals how trans young people are considered pathological and deemed treatable (at the site of the body), in the interest of 'protecting' them from a perceived abject future of trans adulthood. The logic and violence of cisgenderism is uncovered as the foundation of these dominant discourses, whereby growing up cisgender is often presented as the only option in health care settings. The dominant discourses that constitute the trans young person in health care as incongruent, pathological, and vulnerable, alongside the reifying health care responses of dismissal, gatekeeping, and regulation contribute to the erasure of the young trans person.

CONCLUSION

This paper identified key discourses in the literature in how trans young people are constituted and regulated in health care. This review highlights an urgent need for further critical scholarship in trans health by trans researchers, from critical perspectives. Furthermore, it provides a starting point for critical reflection of health care provider and researcher practices and the re-imagination of trans-futurity for all young people in health care.

CLINICAL RELEVANCE

Nurses are situated at the forefront of health care delivery and play a crucial role in the advocacy and provision of culturally safe care. With this ideal proximity to clients, nurses can powerfully affect change through better understanding and reflecting on how regulatory practices constitute and position trans young people in health care. Nursing knowledge, such as cultural safety, can offer novel approaches in working towards safer ways of meeting the needs of trans young people.

Factors that help and hinder transgender and nonbinary youth accessing gender care in Ireland: A multistakeholder exploration

INTRODUCTION

The purpose of this study was to identify the common factors that help and hinder transgender and nonbinary youth accessing gender-specific health care in Ireland and to identify how these factors may be perceived differently by young people seeking gender-affirming care, their parents, and health-care providers.

DESIGN

Qualitative investigation utilizing framework analysis (FA).

METHODS

In-depth one-one interviews were conducted with transgender and nonbinary youth (n = 10), parents of youth (n = 10), and gender-specific health-care providers (n = 10). Maximum variation and snowball sampling were used to recruit participants across Ireland. An interview guide codesigned with an expert panel of gender-diverse youth was utilized. Interviews were audio-recorded and transcribed verbatim. FA was used to code the data and identify key issues and recommendations.

RESULTS

Four themes were derived: (1) "Needing bricks to build" (structural factors); (2) "Enduring and convincing" (diagnostic factors); (3) "Being me, hiding me"; (personal factors); and (4) "It takes a tribe" (interpersonal factors). Each stakeholder group perceived different factors as help or hindrance in accessing care with varying intensities.

CONCLUSIONS

Paramount to the future of gender services in Ireland is the investment of resources for children and young adults. Assessment is likely to remain a component of gender care, but youth recommend distinct revisions to the assessment process. Additional research would be useful in exploring the intersection of neurodiversity and gender as it pertains to health-care navigation. Family and peer support is a strong protective factor and enabler of health-care access among youth.

CLINICAL RELEVANCE

Access to gender-specific health care remains difficult for transgender and non-binary youth. An understanding of the complexity of this healthcare navigation by healthcare professionals may help to mitigate future negative experiences. This study explores some of the clinical considerations that arise for this population from provider perspectives while elucidating the experiences of youth and parents attempting to access care. Further research is needed on longitudinal outcomes following medical and surgical interventions for transgender youth, including nonbinary identities.

Transgender and gender diverse youths' experiences of healthcare: A systematic review of qualitative studies

Transgender and gender-diverse (TGD) populations are identified as high-risk for negative healthcare outcomes. Limited data exists on experiences of TGD youths in healthcare. The review aim is to systematically review literature on healthcare experiences of TGD youths. Seven electronic databases were systematically searched for relevant studies. Pre-determined eligibility criteria were used for inclusion with a double-screening approach. Sixteen studies were included. Studies included were quality appraised, data were extracted, and findings were synthesized narratively. Four narratives were identified including experiences of: accessing care, healthcare settings and services, healthcare providers, and healthcare interventions. Long waiting times, lack of competent providers, and fear were reported as challenges to accessing gender-affirming care. Negative experiences occurred in mental health services and primary care, while school counseling and gender clinics were affirming. Puberty blockers and hormone-replacement therapy were identified as protective factors. TGD youths are at risk of negative health outcomes due to an under resourced healthcare system. Further research is needed to assess interventions implemented to improve TGD youth's experiences.

Adolescent and Caregiver Perspectives on Receiving Gender-Affirming Care in Primary Care

BACKGROUND

Transgender and gender-diverse (TGD) adolescents experience barriers to receiving gender-affirming care. Delivering services in the pediatric primary care setting may help facilitate improved access. With this study, we aimed to explore TGD adolescents' and caregivers' experiences receiving primary care services and their perspectives regarding gender-affirming care delivery in pediatric primary care.

METHODS

TGD adolescents aged 14 to 17 and caregivers of TGD adolescents currently receiving gender-affirming medical care participated in 1-hour-long, semi-structured, individual, virtual interviews. Each interview was recorded and transcribed. Transcripts were then individually coded, and themes were generated iteratively by using a reflexive thematic analysis framework. Recruitment of each group continued until thematic saturation was reached.

RESULTS

A total of 33 participants (15 adolescents and 18 caregivers) completed interviews. Adolescent participants (mean age of 15.7 years) predominantly identified as transmasculine or trans male (73%), and caregiver participants were predominantly mothers (83.3%). Four themes were identified, which included (1) barriers, such as microaggressions and poor psychosocial support, (2) benefits, such as existing trusted relationships with primary care providers (PCPs) and convenience, (3) improvement strategies, such as training and interdisciplinary collaboration, and (4) opportunities for integrating primary care and specialty gender-affirming care.

CONCLUSIONS

TGD adolescents and their caregivers reported previous negative interactions with PCPs; however, some desired to receive gender-affirming care in this setting, citing increased convenience, efficiency, and availability. Participants highlighted an ongoing need for further work to provide resources, education, and training to PCPs and their staff and improve PCP-to-specialist communication and collaboration.

Health Care Disparities Among Autistic LGBTQ+ People

Background

Lesbian, gay, bisexual, transgender, or queer (LGBTQ+) people and disabled people experience disparities in access to health care compared with others. However, we have yet to understand how health care disparities may be further exacerbated at the intersection of disability and LGBTQ+ identity, particularly among autistic people.

Objectives

The primary goals of this study were to (1) examine differences in unmet health care needs and health status between LGBTQ+ autistic people and straight/cisgender autistic people and (2) explore how state policies and demographics predict the unmet health care needs of the autistic LGBTQ+ people.

Methods

We conducted a cross-sectional analysis using data from the 2019 National Survey on Health and Disability that included a subsample of autistic participants, with 62 LGBTQ+ adults and 58 straight/cisgender adults. To address our first study goal, we used an independent samples t-test, and to address our second study goal, we used Poisson regression.

Results

The LGBTQ+ group reported significantly more days of poor physical and mental health, more co-occurring diagnoses, and more unmet health care needs than the straight/cisgender group. For LGBTQ+ people, protective state health care laws and a lower income resulted in significantly more health care needs being met.

Conclusions

Findings from this study suggest that the intersection of an LGBTQ+ identity and autism is associated with greater disparities in physical and mental health as well as unmet health care needs; however, state policies prohibiting discrimination of LGBTQ+ people may act as a protective factor and result in fewer unmet health care needs. Future research should examine additional structural factors that may mitigate health inequities for autistic LGBTQ+ people.

Exploring the Experiences of Autistic Transgender and Non-Binary Adults in Seeking Gender Identity Health Care

Background

This study sought to obtain an in-depth understanding of autistic transgender and/or non-binary adults' experiences in accessing, or trying to access, gender identity health care (GIH). To our knowledge, no prior study researched this topic.

Methods

Through semi-structured interviews, we obtained the first-hand experiences of 17 participants. H.B. (cisgender, non-autistic) conducted a reflexive thematic analysis using an inductive approach, in collaboration with K.M., an autistic transgender disability community researcher, and under the supervision of S.K.K., a cisgender autistic autism researcher.

Results

Thematic analysis determined that poor knowledge of professionals, accessibility issues, and bureaucratic and economic barriers impacted participants' experiences when accessing GIH. Participants experienced a perceived lack of professional knowledge around autism and gender diverse health care needs, limited communication methods and accommodations, and misdiagnosis of mental health difficulties. Accessibility issues included unmet sensory needs, disruption to routine, and a lack of local provision. Further, participants shared that they struggled with unclear processes, standardization of care, long waiting lists, and confusing or inaccessible insurance coverage. Recommendations for improvements highlighted the need to listen to service users to positively impact their experiences in accessing GIH.

Conclusion

This study suggests that more training needs to be given to health care providers and professionals around autistic experience to help improve providers' competence in communication and providing person-centered accommodations. More training around gender diverse identities is needed, as well as increased knowledge on the co-occurrence of autism and transgender/non-binary identities, to positively impact patient experiences and help improve access to care.

Parent reported barriers and facilitators to support services for autistic children in Aotearoa New Zealand

LAY ABSTRACT

Parents might have problems in getting support services for their autistic child due to certain barriers. However, there might also be things that can ease or facilitate parents' access to support services. In this study, New Zealand parents were asked about their experiences in getting support services for their autistic child. We also looked at differences in reported barriers and facilitators based on several demographic factors with a focus on family level of financial resourcing. A total of 173 parents completed a survey. The results suggested that parents experienced several barriers, particularly related to service pathways. Facilitators were also experienced, predominantly related to providers. Financial resourcing predicted the number of parent-reported barriers. Both lower level of family financial resourcing and having a non-binary child predicted parents' rating of the extent of barriers. Child age and level of speech were predictors for reports of experiencing a higher number of facilitators, with parents of younger children or of non-speaking autistic children reporting a greater number of facilitators. We discuss how these results may be useful to support service delivery and identify areas for future research.

Risk and protective factors for new-onset binge eating, low weight, and self-harm symptoms in >35,000 individuals in the UK during the COVID-19 pandemic

OBJECTIVE

The disruption caused by the COVID-19 pandemic has been associated with poor mental health, including increases in eating disorders and self-harm symptoms. We investigated risk and protective factors for the new onset of these symptoms during the pandemic.

METHOD

Data were from the COVID-19 Psychiatry and Neurological Genetics study and the Repeated Assessment of Mental health in Pandemics Study (n = 36,715). Exposures were socio-demographic characteristics, lifetime psychiatric disorder, and COVID-related variables, including SARS-CoV-2 infection/illness with COVID-19. We identified four subsamples of participants without pre-pandemic experience of our outcomes: binge eating (n = 24,211), low weight (n = 24,364), suicidal and/or self-harm ideation (n = 18,040), and self-harm (n = 29,948). Participants reported on our outcomes at frequent intervals (fortnightly to monthly). We fitted multiple logistic regression models to identify factors associated with the new onset of our outcomes.

RESULTS

Within each subsample, new onset was reported by: 21% for binge eating, 10.8% for low weight, 23.5% for suicidal and/or self-harm ideation, and 3.5% for self-harm. Shared risk factors included having a lifetime psychiatric disorder, not being in paid employment, higher pandemic worry scores, and being racially minoritized. Conversely, infection with SARS-CoV-2/illness with COVID-19 was linked to lower odds of binge eating, low weight, and suicidal and/or self-harm ideation.

DISCUSSION

Overall, we detected shared risk factors that may drive the comorbidity between eating disorders and self-harm. Subgroups of individuals with these risk factors may require more frequent monitoring during future pandemics.

PUBLIC SIGNIFICANCE

In a sample of 35,000 UK residents, people who had a psychiatric disorder, identified as being part of a racially minoritized group, were not in paid employment, or were more worried about the pandemic were more likely to experience binge eating, low weight, suicidal and/or self-harm ideation, and self-harm for the first time during the pandemic. People with these risk factors may need particular attention during future pandemics to enable early identification of new psychiatric symptoms.

Integral health care for transgender adolescents: subsidies for nursing practice

OBJECTIVE

to analyze the integral health care for transgender adolescents from the perspective of their guardians.

METHOD

qualitative research based on the Social Network framework proposed by Lia Sanicola, developed with 22 guardians of transgender adolescents in Brazil through semi-structured individual online interviews. The empirical material was analyzed using the content analysis technique, thematic modality.

RESULTS

lack of ambience was observed, in addition to technical unpreparedness of health professionals in relation to the theme at all levels of care, transphobia, centralization of care in scarce qualified services for transgender children and youth, absence of family support, lack of health promotion actions within the community, especially in the school environment, and the common support from non-governmental initiatives.

CONCLUSION

the centralization of actions in scarce specialized services in the country, and the structural transphobia can compromise the integral health care for transgender adolescents. There is an urgent need for a network of care capable of assisting the joint action by multi and interdisciplinary teams, with greater proactivity of the nurse with the transgender adolescent and their guardians in individual and collective actions; ambience; health promotion in schools for visibility and support in Primary Health Care since childhood.

HIGHLIGHTS

(1) Need for a network of care concerning integral health care for transgender adolescents.(2) Centralization and scarce qualified services for transgender children and youth.(3) Invisible families, lack of health promotion within the community.(4) Unpreparedness of health professionals and disarticulation of the health care network.(5) Need for qualification of nurses when caring for transgender people.

Transgender and non-binary demographics, referrals, and comorbidities among young Irish adults (2014-2020)

BACKGROUND

Over the last 6 years, there has been a change in the demographics of people presenting to gender services in Ireland. This is in line with international trends describing a higher number of transgender men (Female-Male, FTM, AFAB) presenting to gender services as compared to transgender women (Male-Female, MTF, AMAB), and lower ages at referral. Given the changes in demographics, it would be anticipated that clinical needs may have changed. This study describes the demographics of a young Irish sample (participants aged 18-30 years old) and explores the referral pathways and clinical needs of this cohort.

METHODS

The study was performed as a retrospective chart review of 167 charts at The National Gender Service in Ireland over a five-month period.

RESULTS

Transgender men represented 62.3% of the sample, transgender women 35.3%, and transmasculine/non-binary individuals represented 2.4%. Over two-thirds of participants were on gender affirming hormone therapy or GnRH antagonists and 16.1% had undergone surgical interventions. The median time from referral received to being seen at the clinic was 450 days (481 mean). Mental health comorbidities remain high with 49.1% of youth experiencing depression, a further 15.6% low mood and 26.3% anxiety.

CONCLUSION

This is the first study to show increasing referrals of people who were assigned female at birth (AFAB) over assigned male at birth (AMAB) individuals in Ireland, and to document the clinical needs of this cohort. By understanding the changing demographics and clinical needs, we can better plan for care and service improvements.

Support for Mothers, Fathers, or Guardians of Transgender Children and Adolescents: A Systematic Review on the Dynamics of Secondary Social Networks

Mothers', fathers', or guardians' support for disclosures of diverse gender identity has significant relationships with decreased suicidality for transgender children and adolescents. They play an essential role in facing transphobia, protecting trans children, and strengthening the expression of their identity. These guardians need structural, emotional, and informative support; they need to be prepared to recognize and manage of their own feelings, as well as deal with the challenges that come with new social contexts of transphobia in schools, health institutions, and other community spaces. This study aimed to analyze the scientific evidence on the dynamics of secondary social networks to support mothers, fathers, or guardians of transgender children and adolescents. This is a systematic review of qualitative studies, guided by PRISMA guidelines. Controlled and free vocabularies were used to survey the primary studies in the following databases: EMBASE; Scopus; MEDLINE; Cumulative Index to Nursing and Allied Health Literature (CINAHL); PsycInfo; Latin American and Caribbean Literature in Health Sciences (LILACS); and Web of Science. A total of 28 articles made up the final sample of this review. Secondary social networks were described as fragile, characterized by conflicting and broken ties with healthcare services and professionals, isolation and unpreparedness from schools, and emotional and informational support from peer groups and some qualified healthcare professionals. The literature shows the potential of the dynamics of secondary social support networks; however, it presented the unpreparedness of professionals and institutional policies for welcoming transgender children and adolescents and their families, with the peer group being the main emotional and informative support network.

Dynamics of Primary Social Networks to Support Mothers, Fathers, or Guardians of Transgender Children and Adolescents: A Systematic Review

Mothers, fathers, or guardians of children and adolescents who do not identify with the gender they were assigned at birth face barriers in their social network to recognize their children’s gender identity. This study aimed to analyze the scientific evidence on the dynamics of primary social networks to support mothers, fathers, or guardians of transgender children and adolescents. This is a systematic review of qualitative studies guided by the PRISMA guidelines. Controlled and free vocabulary were used to survey the studies in the EMBASE, Scopus, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Latin American and Caribbean Literature in Health Sciences (LILACS), and Web of Science databases. A total of 21 studies composed the final sample. Primary social networks were described as fragile and conflicting family/blood relationship ties with disapproval, isolation, rejection, a lack of understanding, and feelings of exclusion were expressed. Some have lost friends, reported tension in marriage and with relatives, and were commonly treated with hostility and harassment. Social transition does take place in the mutual context of struggle and resistance which demands a support network for parents or guardians.

The Cisnormative Blindspot Explained: Healthcare Experiences of Trans Men and Non-Binary Persons and the accessibility to inclusive sexual & reproductive Healthcare, an integrative review

Trans men and non-binary persons assigned female at birth (AFAB) often encounter resistance and reluctance pertaining to their healthcare needs. As a result of patriarchal-based decision-making and cis-heteronormative ideologies, the trans and gender diverse (TGD) population is routinely left out of representation in research, education, and healthcare. The aim of this integrative literature review is to describe the experiences of trans men and non-binary persons AFAB in healthcare interactions and their sexual and reproductive healthcare needs. A total of 32 articles were analyzed, synthesized, and reconceptualized through joint inductive and deductive analysis with a transfeminist and intersectional lens. From these papers, two broader concepts emerged with five sub-concepts that portrayed underlying barriers to care (primed with fear, onus of self-advocacy, and call for competence) and internalized ideologies (pregnancy incompatibility and presumptive care). A multidisciplinary approach is essential to employ in implementation efforts involving improved standards of care and in achieving desired family planning. As this is not as linear as addressing a knowledge gap, but one of deeper set intrinsic ideologies, instruction on the necessary impact of continued education and peer learning within the context of in-group dynamics can help the efficiency of designated change agents within the healthcare systems themselves.

"Am I really alive?": Understanding the role of homophobia, biphobia and transphobia in young LGBT+ people's suicidal distress

Suicide is the fourth leading cause of death amongst young people aged 15-29 globally and amongst this young population, lesbian, gay, bisexual and trans (LGBT+) young people have higher rates of suicidal thoughts and attempts than their cisgender (non-trans), heterosexual peers. However, despite well-established knowledge on the existence of this health inequality, in the UK there has been a paucity of research exploring why this disparity exists, and this is particularly the case in Scotland. This paper aims to address this gap, reporting on the first study specifically seeking to understand LGBT+ young people's suicidal thoughts and attempts in Scotland. We used a qualitative methodology to explore how young people with lived experience of suicidal distress make sense of the relationship between homophobia, biphobia and transphobia, and suicidal thoughts and attempts. We undertook in-depth, narrative interviews with twenty-four LGBT+ people aged 16-24, and analysed them using reflexive thematic analysis. Drawing on this analysis, we argue that suicide can be understood as a response to stigma, discrimination and harassment, made possible by a cultural climate that positions LGBT+ people as different or other, reinforcing norms regarding gender conformity and sexuality. We suggest in turn, that this cultural climate provides fertile ground from which more explicit acts of homophobia, biphobia and transphobia, such as bullying and family rejection are able to grow. In response to this, LGBT+ young people could begin to experience senses of entrapment, rejection and isolation, to which suicidal thoughts and attempts can be understood as responses. Consequently, we propose that these stigma experiences must be taken seriously and tackled directly in order to reduce LGBT + suicide in the future.

Study protocol: navigating access to gender care in Ireland-a mixed-method study on the experiences of transgender and non-binary youth

INTRODUCTION

There has been a global increase in demand for gender-specific healthcare services and a recognition that healthcare access is complex and convoluted, even in countries with well-developed healthcare services. Despite evidence in Ireland supporting the improvement in physical and mental health following access to gender care, little is known about the local healthcare navigation challenges. Internationally, research focuses primarily on the experience of service users and omits the perspective of other potential key stakeholders. Youth experiences are a particularly seldom-heard group.

METHODS AND ANALYSIS

This study will use a sequential exploratory mixed-methods design with a participatory social justice approach. The qualitative phase will explore factors that help and hinder access to gender care for young people in Ireland. This will be explored from multiple stakeholders' perspectives, namely, young people, caregivers and specialist healthcare providers. Framework analysis will be used to identify priorities for action and the qualitative findings used to build a survey tool for the quantitative phase. The quantitative phase will then measure the burden of the identified factors on healthcare navigation across different age categories and gender identities (transmasculine vs transfeminine vs non-binary).

ETHICS AND DISSEMINATION

This study has been approved by St Vincent's Hospital Research Ethics Committee (RS21-019), University College Dublin Ethics Committee (LS-21-14Kearns-OShea) and the Transgender Equality Network Ireland's Internal Ethics Committee (TIECSK). We aim to disseminate the findings through international conferences, peer-review journals and by utilisation of expert panel members and strategic partners.

Transgender data collection in the electronic health record: Current concepts and issues

There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.

Atención integral a la salud de los adolescentes transgénero: subsidios para la práctica de la Enfermería

Resumen Objetivo: analizar la atención integral a la salud de los adolescentes transgénero desde la perspectiva de sus responsables. Método: estudio cualitativo basado en el marco de la Red Social propuesto por Lia Sanicola, desarrollado con 22 responsables de adolescentes transgénero en Brasil a partir de entrevistas en línea individuales semiestructuradas. El material empírico fue analizado mediante la técnica de análisis de contenido, modalidad temática. Resultados: se ha evidenciado la falta de ambiente y preparación técnica de los profesionales de la salud con relación al tema en todos los niveles de atención, transfobia, centralización del cuidado en los pocos servicios habilitados para personas trans en el período infantojuvenil, invisibilidad del apoyo a la familia, ausencia de acciones de promoción de la salud en el ámbito comunitario, especialmente en la escuela, y la acogida comúnmente por las iniciativas no gubernamentales. Conclusión: la centralización de acciones en los pocos servicios especializados del país y la transfobia estructural pueden comprometer la atención integral en salud de los adolescentes trans. Urge una línea de cuidado capaz de auxiliar la acción conjunta de un equipo multi e interdisciplinario, con mayor proactividad del enfermero con el adolescente transgénero y sus responsables en acciones individuales y colectivas; ambiente; promoción de la salud en las escuelas para la visibilidad y acogida en la Atención Primaria de la Salud desde la infancia.

Atenção integral à saúde dos adolescentes transgêneros: subsídios para a prática da Enfermagem

Resumo Objetivo: analisar a atenção integral à saúde dos adolescentes transgêneros na perspectiva dos seus responsáveis. Método: estudo qualitativo fundamentado no referencial Rede Social proposto por Lia Sanicola, desenvolvido com 22 responsáveis por adolescentes transgêneros no Brasil por meio de entrevistas online individuais semiestruturadas. O material empírico foi analisado com a utilização da técnica de análise de conteúdo na modalidade temática. Resultados: Foram evidenciados a falta de ambiência e despreparo técnico de profissionais da saúde em relação à temática em todos os níveis de atenção, transfobia, centralização do cuidado em escassos serviços habilitados para pessoas trans no período infantojuvenil, invisibilidade do apoio à família, ausência de ações de promoção da saúde no âmbito comunitário, sobretudo, escolar, e, ainda, o acolhimento promovido, comumente, pelas iniciativas não governamentais. Conclusão: a centralização de ações em escassos serviços especializados no país e a transfobia estrutural podem comprometer a atenção integral à saúde dos adolescentes trans. Urge a necessidade de uma linha de cuidado capaz de auxiliar a atuação conjunta por equipe multi e interdisciplinar com maior proatividade do enfermeiro junto ao adolescente trans e seus responsáveis por meio de ações individuais e coletivas; ambiência; promoção da saúde nas escolas para visibilidade e acolhimento na Atenção Primária à Saúde desde a infância.

"It felt like they were trying to destabilise us": Parent assessment in UK children's gender services

Background: Pediatric gender clinics have a long history of analyzing and scrutinizing parents of trans children. At present, gender services in countries like the UK continue to hold clinical sessions with parents of pre-adolescent transgender children, sometimes extending over many years. Clinician viewpoints dominate the limited existing literature, with little analysis of the perspectives of parents of trans children. Aims: The study aimed to understand the experiences that parents of socially transitioned pre-adolescent trans children have had in UK gender clinics. Methods: Data were drawn from semi-structured qualitative interviews with 30 UK-based parents of socially transitioned trans children - children who socially transitioned, for example, changed pronoun, under the age of eleven. This article analyzed a subset of a wider dataset, focusing on data from 23 parents relating to parental engagement with UK NHS gender clinics before their child reached adolescence. Results: Themes emerging from the dataset included parents feeling under a microscope, and parents finding gender clinic sessions judgemental, intrusive and inappropriate. Interviewees reported clinician discouragement of listening to and validating their children, as well as a lack of emotional support. Discussion: The article presents evidence of continued pathologisation and problematisation of childhood gender diversity in parental engagements with UK children's gender clinics. It concludes by contrasting current UK practice as described in parental accounts with gender affirmative approaches to supporting parents of trans children.

Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography

Objective

Transgender and non-binary individuals frequently engage with healthcare services to obtain gender-affirming care. Little data exist on the experiences of young people accessing gender care. This systematic review and meta-ethnography aimed to identify and synthesise data on youths’ experiences accessing gender-affirming healthcare.

Method

A systematic review and meta-ethnography focusing on qualitative research on the experiences of transgender and non-binary youth accessing gender care was completed between April-December 2020. The following databases were used: PsychINFO, MEDLINE, EMBASE, and CINAHL. The protocol was registered on PROSPERO, international prospective register of Systematic Reviews (CRD42020139908).

Results

Ten studies were included in the final review. The sample included participants with diverse gender identities and included the perspective of parents/caregivers. Five dimensions (third-order constructs) were identified and contextualized into the following themes: 1.) Disclosure of gender identity. 2.) The pursuit of care. 3.) The cost of care. 4.) Complex family/caregiver dynamics. 5.) Patient-provider relationships. Each dimension details a complicated set of factors that can impact healthcare navigation and are explained through a new conceptual model titled “The Rainbow Brick Road”.

Conclusion

This synthesis expands understanding into the experience of transgender and non-binary youth accessing gender-affirming healthcare. Ryvicker’s behavioural-ecological model of healthcare navigation is discussed in relation to the findings and compared to the authors’ conceptual model. This detailed analysis reveals unique insights on healthcare navigation challenges and the traits, resources, and infrastructure needed to overcome these. Importantly, this paper reveals the critical need for more research with non-binary youth and research which includes the population in the design.

'This family rejection harmed my health as well': Intersections between the meanings of family and health for trans people and family members in a trans healthcare service in Brazil

Transgender people deal with intense discrimination in every aspect of life. These experiences increase when they face family rejection. The research on social and family environment surrounding gender transition has been largely overlooked. We examine the meanings of family and health, and how these intersect, among trans people and their family members in a health service in Brazil. We conducted a qualitative study (between December 2017 and July 2018), an ethnography with the triangulation of three sources: interviews with 8 transgender men, 8 transgender women and 5 family members; a focus group with another 8 transgender men and approximately 100 h of field observation. Our study shows that family and health are interpreted as ideal protective environments, and seen as causes of disappointment, abandonment and illness. The meanings of family and health are interconnected and constituted in relation to each other. We also found that there are differences within these meanings of family and health when we consider the ethnicity and the economic status of the participants. The participants reported that the society education towards transsexuality is fundamental to improving trans people's quality of life. Our results challenge health services to provide comprehensive healthcare and assure health equity for transgender people.

Expanding and improving trans affirming care in Australia: experiences with healthcare professionals among transgender young people and their parents

Access to medical care is significant for many transgender young people and their families, which involves interactions with healthcare professionals. While a trans affirming model is used across Australian paediatric gender clinics, this does not automatically mean that all transgender young people and their parents experience the care they receive as affirming. This article considers the experiences and views of transgender young people (aged 11-17) and their parents in relation to healthcare professionals inside and outside of gender clinics in Australia. Ten qualitative interviews were conducted with parent-child dyads in two Australian states. Key themes relating to healthcare professionals were: differing levels of healthcare professional knowledge and affirmation, quality of service is dependent on individual healthcare professionals, and lack of connected services and referral pathways. The discussion explores specific issues arising from the findings that suggest implications for training for healthcare professionals so as to be better equipped to provide trans affirming clinical care.

Support for parents/carers of primary school aged gender diverse children in England, UK: a mixed-method analysis of experiences with health services

This paper presents findings from a UK mixed-method study that aimed to understand parents/carers' views and experiences of support received from health services for primary school age (4-11) gender diverse children and their families. Data was collected via an e-survey including 10 open-ended questions with 75 parents/carers addressing experiences with (i) primary health services, including general practice (GP) clinics and child and adolescent mental health services (CAMHS) (ii) specialist gender identity development services (GIDS) (iii) non-health related support including transgender groups and online resources. Findings are organised into four themes: 'journey to health service provision', 'view on health services used', 'waiting' and 'isolation'. Discourses about gender diversity, childhood and the validity of trans healthcare shape parental experiences, including their desire for better information, more certainty in healthcare pathways and more expedient access to support services to reduce anxiety, distress and isolation. The emotional costs of waiting are compounded by the material costs of accessing the limited number of specialist services. Experiences could be improved through ensuring GPs and CAMHS are better prepared, expanding access to trans-specific support groups for those caring for children and young people, and exploring the provision of school-based support for gender diverse primary-age children.

"It's like my kid came back overnight": Experiences of trans and non-binary young people and their families seeking, finding and engaging with clinical care in England

Background

Trans and non-binary children and young people in England, UK struggle to gain access to affirming clinical care, despite the international research evidence pointing toward this best practice approach. Concurrently, they are subject to constant discussion in the UK national media and politics, where many negative assumptions are made about their needs, experiences and clinical provision. Their journey to seek appropriate care has not yet been documented.

Aims

We trace the experiences of trans and non-binary children and youth and their families in their decision to seek, searches for and experiences with affirmative and non-affirmative clinical input for help with their gender.

Method

27 dyadic, semi-structured interviews were undertaken with trans and non-binary children and young people and their parents from 13 families.

Results

The process of seeking support via National Health Service clinical routes in England, UK is beset with lengthy waiting lists, issues with geographical inaccessibility, a lack of relevant clinical knowledge, and a failure to recognize the value of family expertise. Family doctors provide contraceptive hormones in lieu of proper access to puberty blocking or gender affirming hormones, and most families resort to private care they can ill afford.

Discussion

Training in gender identity and gender dysphoria is recommended for both family doctors, and children's mental health services. Gender identity development services could be decentralized, with local hubs offering more accessible support.