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

Sameness across Difference: A Postcolonial Feminist Analysis of Gender-Affirming Health Care in Thailand and the United States

Joining a growing body of research calling for the integration of social analysis and postcolonial theory, recent work in medical sociology has analyzed health, illness, and medicine from a postcolonial lens. In this article, I argue for a postcolonial feminist approach to medical sociology that builds on this extant work while challenging methodological nationalism and cultural essentialism. Based on an analysis of gender-affirming health care for transgender and gender diverse (TGD) people in Thailand and the United States, I propose "sameness across difference" as a framework to analyze commonalities in the health care experiences of marginalized populations across nations as the products of imperial legacies. Drawing on 83 interviews with health care providers, TGD patients, and TGD activists, I demonstrate the role of imperialism in sustaining barriers to gender-affirming health care through the uneven geographic distribution of care across rural and urban areas and the reinforcement of racial and class hierarchies within cities.

Examining gender-specific mental health risks after gender-affirming surgery: a national database study

BACKGROUND

Transgender individuals face heightened psychological distress, including depression, anxiety, and suicidal ideation, partly due to stigma and lack of gender affirmation.

AIM

To evaluate mental health outcomes in transgender individuals with gender dysphoria who have undergone gender-affirming surgery, stratified by gender and time since surgery.

METHODS

This retrospective study utilized the TriNetX database, analyzing U.S. patients aged ≥18 with gender dysphoria (International Classification of Diseases, Tenth Revision [ICD-10] F64) between June 2014 and June 2024. Six cohorts were created based on gender and surgery status: Cohorts A-D included patients with or without surgery, and Cohorts E-F allowed for gender comparison among those with surgery. Propensity score matching controlled for age, race, and ethnicity. Mental health outcomes included depression, anxiety, suicidal ideation, substance use disorder, and body dysmorphic disorder, assessed over two years post-surgery using clinician-verified ICD-10 codes. Body dysmorphic disorder (BDD) was analyzed separately and not conflated with gender dysphoria cohorts to ensure the distinction between these conditions. Statistical analysis employed risk ratios, with P < 0.05 deemed significant.

OUTCOMES

Primary outcomes were differences in mental health disorders, specifically depression, anxiety, suicidal ideation, body-dysmorphic disorder, and substance use disorder, among transgender individuals' post-surgery.

RESULTS

From 107 583 patients, matched cohorts demonstrated that those undergoing surgery were at significantly higher risk for depression, anxiety, suicidal ideation, and substance use disorders than those without surgery. Males with surgery showed a higher prevalence of depression (25.4% vs. 11.5%, RR 2.203, P < 0.0001) and anxiety (12.8% vs. 2.6%, RR 4.882, P < 0.0001). Females exhibited similar trends, with elevated depression (22.9% vs. 14.6%, RR 1.563, P < 0.0001) and anxiety (10.5% vs. 7.1%, RR 1.478, P < 0.0001). Feminizing individuals demonstrated particularly high risk for depression (RR 1.783, P = 0.0298) and substance use disorders (RR 1.284, P < 0.0001).

CLINICAL IMPLICATIONS

Findings suggest the necessity for gender-sensitive mental health support following gender-affirming surgery to address post-surgical psychological risks.

STRENGTHS AND LIMITATIONS

By leveraging ICD-10 codes, we provide a more accurate representation of patient demographics and clinical outcomes, minimizing recall and reporting biases that often limit survey-based research. Limitations include the inability to account for unmeasured confounders such as social support.

CONCLUSION

Gender-affirming surgery, while beneficial in affirming gender identity, is associated with increased risk of mental health issues, underscoring the need for ongoing, gender-sensitive mental health support for transgender individuals' post-surgery.

Transgender people's experiences of hospitalization: A qualitative metasynthesis

AIM

To identify, synthesize, and interpret the scientific literature on the experience, perspectives, and feelings of transgender people during hospitalization.

DESIGN

A qualitative metasynthesis.

DATA SOURCES

PubMed, CINAHL and PSYCHINFO were consulted in March 2024.

METHODS

A literature review was conducted following Sandelowski and Barroso's four-step metasynthesis methodology. The article selection process was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies were selected based on the objectives of the review, pre-established criteria and quality appraisal. A thematic analysis was conducted after extracting relevant quotations and a metasynthesis table was created to compare quotations and analyse overarching themes.

RESULTS

Twenty-two studies were included after screening titles and abstracts, full texts, and references. Three themes were identified: 'Perception of self-identity'; 'Misgendering' and 'Lack of staff training and awareness'.

CONCLUSION

Transgender people's healthcare experiences during hospitalization were mainly negative, delayed or uncomfortable. Misgendering and lack of awareness of transgender issues among healthcare workers generated anxiety and frustration. Key aspects of care for transgender people need to be included in all training programs for health professionals.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

There is a need to increase education and awareness among healthcare professionals towards transgender people's needs during hospitalization ensure high quality care.

IMPACT

This study addressed the negative experience, perspectives and feelings of transgender people during hospitalization. Misgendering and unawareness of transgender peoples' issues create anxiety and frustration among nurses. Elements to improve care for transgender people need to be integrated into all nursing curricula and training programs.

REPORTING METHOD

The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and the Critical Appraisal Skills Programme (CASP).

PATIENT OR PUBLIC CONTRIBUTION

Since this was a metasynthesis, no patient or public contribution was required.

The medical institution and transgender health: The role of healthcare barriers and negative healthcare experiences

Transgender health has risen as a topic of key interest. Yet little is known about factors that might stratify health among transgender people. In this paper, we suggest that the medical institution, which both prevents and provides access to transition-related care and thus sociolegal recognition for many transgender people, is a key institution for the health of transgender people. Drawing on 2015 US Transgender Survey data (USTS; N = 27,715), we examine whether transgender people who report barriers to healthcare and negative healthcare experiences have worse health than transgender people who do not. We contextualize the USTS sample against, and replicate our analyses when possible with, a probability-based sample of transgender people from the 2014-2017 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,386). We find that transgender people who have unmet medical needs and negative healthcare experiences have worse self-rated health than their transgender counterparts who do not. Findings also suggest that such barriers and experiences are more negatively associated with the health of non-binary/genderqueer people compared with transgender men and transgender women. Our study moves past prior work documenting a transgender health disadvantage by identifying specific characteristics associated with poor health of transgender people and by illuminating heterogeneity in such associations.

Delivering an Inclusive Experience for Patients of All Genders in the Aesthetics Practice: A Roundtable Discussion

Transgender, nonbinary, and gender-diverse individuals represent a growing proportion of patients desiring minimally invasive aesthetic treatments to enhance facial appearance. Although awareness of the need for gender-affirming care is increasing and resources are available on approaches to injection in gender-diverse individuals, guidance on how to best provide this care is lacking. The objective of this manuscript is to share recommended practices for aesthetic clinicians who wish to treat transgender, nonbinary, and gender-diverse individuals or wish to improve gender inclusivity within their aesthetic practices. As part of a continuing medical education activity, the authors participated in a roundtable discussion on how individual practices can support inclusive care for transgender, nonbinary, and cisgender patients. The authors agreed that a thorough understanding of vocabulary in support of gender diversity can help to improve clinician confidence and the patient experience. Consideration of clinic design, including the use of gender-neutral bathrooms and the display of gender diversity in advertisements or clinic artwork, can also support a gender-inclusive and welcoming environment. The use of correct pronouns and gender-neutral language by all clinic staff and clinicians, as well as a thoughtful approach to language used on intake forms, may also help to provide an inclusive and safe space for the transgender, nonbinary, and gender-diverse community. Inclusive and gender-affirming healthcare improves the mental health and well-being of transgender, nonbinary, and gender-diverse populations. Individual aesthetic clinicians can improve inclusivity by considering their advertising, clinic design, intake forms as well as their consultation, treatment, and follow-up practices.

Level of Evidence 5 Therapeutic

Exploring the utilization of targeted intervention services by transgender individuals in Uttarakhand, India: a qualitative study

Purpose

Transgender (TG) women face violence, discrimination, and stigma, which affect their mental health and hinder their access to targeted intervention (TI) services. This lack of access may increase the risk of human immunodeficiency virus/sexually transmitted infections (HIV/STIs). However, the utilization of TI services among transgender women in Uttarakhand, as well as across the country, remains understudied. The purpose of this study is to explore the utilization of TI services by the transgender community in Uttarakhand.

Methods

This qualitative study focused on non-government organizations (NGOs) that implement TI projects in Haridwar and Roorkee, Uttarakhand, India. From September 2023 to January 2024, 5 focus group discussions (FGDs) involving 24 transgender women and 9 in-depth interviews (IDIs) involving NGO staff were conducted. Thematic analysis, guided by the Anderson and Newman healthcare utilization model, was employed.

Results

Several barriers to service utilization were identified, including ritual beliefs, low health literacy, stigma, social isolation, financial insecurity, privacy concerns, and inefficient service delivery. Challenges in the implementation of the STI program and neglect of transgender women in health facilities were also reported. However, enabling factors such as trusted providers, supportive laws, and initiatives by NGOs and government agencies were recognized. Nonetheless, there remains a significant need for information on gender-affirming services and addressing other prevalent health issues within the transgender female community.

Conclusion

The study underscores the interplay of individual, social, and service-related factors affecting healthcare access among transgender women. Inclusive and high-quality healthcare services are necessary to address the complex sociocultural aspects influencing transgender women's healthcare access and utilization.

Improving Knowledge and Competency in Gender-Affirming Patient Care Among New Nurses in Sexual and Reproductive Health Care

OBJECTIVE

To improve knowledge and competency in providing gender-affirming patient care among newly licensed registered nurses (RNs) working in sexual and reproductive health (SRH).

DESIGN

Pilot, pretest/posttest, descriptive design.

SETTING AND PARTICIPANTS

Participating RNs were employed at a large academic health center in the southeastern United States. All RNs were providing SRH nursing and participating in the health center's new nurse residency program.

METHODS AND INTERVENTION

Participants completed an online synchronous training that introduced topics such as sex versus gender, gender dysphoria, and health disparities. This education was followed by in-person training, where an unfolding case study applied concepts to theoretical patient scenarios specific to reproductive health. Participants completed a 20-item survey with a single assessment retrospective pre-post design to measure change in knowledge and competency.

RESULTS

Twelve RNs participated in this pilot study. Fewer than half had previously received instruction on providing care to trans∗ persons. Seven self-perceived knowledge and competency areas were evaluated with paired retrospective pre-post design questions. All areas measured showed increases from pretraining to posttraining. Participants also had the opportunity to respond to open-ended questions. Common themes identified in these responses include participants planning to maintain a greater awareness and intentionality with language and abandoning cisgender assumptions. Several participants also described health care-specific systemic barriers that could prevent a trans∗ patient from feeling comfortable.

CONCLUSION

Providing new graduate nurses with education specific to trans∗ patients may help them to feel more knowledgeable and competent when caring for these individuals in SRH settings.

Gender affirming care for the minimally invasive gynecologic surgeon

PURPOSE OF REVIEW

Given the current political climate and the release of an updated version of the World Professional Association for Transgender Health's guidelines, this review assesses recent updates in the care of transgender and gender diverse (TGD) patients, specifically related to care provided by gynecologists.

RECENT FINDINGS

The number of people identifying as TGD and pursuing gender affirming care is increasing. Contraception for these patients is underdiscussed and high rates of pelvic pain and irregular bleeding were identified. Rates of regret are low following gender affirming surgeries, and studies have repeatedly shown their benefits for gender dysphoria. A minimally invasive approach is recommended for gender affirming hysterectomy, and the decision to proceed with bilateral salpingo-oophorectomy should be based on shared decision making. Surgical techniques include ensuring an adequate margin when taking the infundibulopelvic ligament, and consideration for two-layer vaginal cuff closure.

SUMMARY

Gynecologists play a key role in the care of TGD patients. Recent reviews have found extensive gaps in our knowledge, including a lack of guidelines for cancer prevention, effects of testosterone on benign conditions, and the long-term effects of bilateral salpingo-oophorectomy on health outcomes for patients on testosterone.

Ocular Syphilis in an HIV-Positive Transgender Female: A Case Report

This is a case of a 56-year-old transgender female with a history of HIV who presented to the emergency department with visual disturbances and bilateral papilledema. Initially, intracranial abnormalities were ruled out through imaging studies. However, a lumbar puncture later confirmed the presence of syphilis in the cerebral spinal fluid (CSF), and the patient was diagnosed with bilateral syphilitic uveitis by a retina specialist. Treatment with intravenous and intramuscular penicillin led to significant improvement in her visual symptoms and resolution of optic nerve edema. This case underscores the importance of early screening for syphilis and other sexually transmitted infections (STIs) in transgender patients living with HIV presenting with visual symptoms. The delayed syphilis screening and treatment in this patient highlight the impact of healthcare barriers on transgender individuals. Prompt diagnosis and treatment are critical to prevent serious complications, such as permanent vision loss. Healthcare providers must maintain a high index of suspicion for syphilis in HIV-positive patients with visual symptoms, irrespective of their cluster of differentiation 4 (CD4) count or viral load. Addressing barriers to healthcare for transgender individuals is essential to ensure timely diagnosis and treatment to improve patient outcomes.

A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape

The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.

A sex- and gender-based analysis of alcohol treatment intervention research involving youth: A methodological systematic review

BACKGROUND

While there is widespread consensus that sex- and gender-related factors are important for how interventions are designed, implemented, and evaluated, it is not currently known how alcohol treatment research accounts for sex characteristics and/or gender identities and modalities. This methodological systematic review documents and assesses how sex characteristics, gender identities, and gender modalities are operationalized in alcohol treatment intervention research involving youth.

METHODS AND FINDINGS

We searched MEDLINE, Embase, Cochrane Central Registry of Controlled Trials, PsycINFO, CINAHL, LGBT Life, Google Scholar, Web of Science, and grey literature from 2008 to 2023. We included articles that reported genders and/or sexes of participants 30 years of age and under and screened participants using AUDIT, AUDIT-C, or a structured interview using DSM-IV criteria. We limited the inclusion to studies that enrolled participants in alcohol treatment interventions and used a quantitative study design. We provide a narrative overview of the findings. Of 8,019 studies screened for inclusion, 86 articles were included in the review. None of the studies defined, measured, and reported both sex and gender variables accurately. Only 2 studies reported including trans participants. Most of the studies used gender or sex measures as a covariate to control for the effects of sex or gender on the intervention but did not discuss the rationale for or implications of this procedure.

CONCLUSIONS

Our findings identify that the majority of alcohol treatment intervention research with youth conflate sex and gender factors, including terminologically, conceptually, and methodologically. Based on these findings, we recommend future research in this area define and account for a spectrum of gender modalities, identities, and/or sex characteristics throughout the research life cycle, including during study design, data collection, data analysis, and reporting. It is also imperative that sex and gender variables are used expansively to ensure that intersex and trans youth are meaningfully integrated.

TRIAL REGISTRATION

Registration: PROSPERO, registration number: CRD42019119408.

Understanding harms associated with gender identity conversion efforts among transgender and nonbinary individuals: The role of preexisting mental well-being

Background: Affirmation of gender identity is critical for the mental health and overall well-being of transgender and nonbinary (TNB) persons. Gender identity conversion efforts (GICE), an outlawed practice for licensed professionals in numerous U.S. jurisdictions, have been associated with negative mental health and substance use outcomes. Limited previous literature examining GICE exposure has been criticized for failing to distinguish mental well-being for TNB persons before or after GICE. Our study builds on current literature by examining differences in TNB persons' psychosocial risk indicators based on their GICE exposure, accounting for pre-GICE mental well-being. Methods: We conducted a secondary data analysis using the 2015 U.S. Transgender Survey (N = 25,810), the largest available national survey aimed at understanding TNB persons' experiences. Using logistic regression models, we examined how GICE exposure (disaggregated by temporal precedence of initial suicide attempts) is related to health (psychological distress, extra-medical prescription use, healthcare avoidance), socio-structural (public restroom avoidance, housing instability), and interpersonal outcomes (sexual assault, emotional and physical intimate partner violence (IPV)). Results and conclusions: Initiating a suicide attempt post-GICE or in the absence of GICE were the only consistently significant predictors of poor outcomes across all domains compared to participants who never experienced GICE or attempted suicide. Findings suggest, however, that a combination of GICE with a history of suicide attempts (pre- or post-GICE) was indicative of the highest risk across outcomes, highlighting the particularly hazardous nature of combining poor mental well-being and GICE exposures. Our study adds much-needed complexity to our understanding of how GICE exposure's role in the well-being of TNB persons may differ related to their pre-GICE mental health. Our findings add further credence to previous studies identifying harms associated with GICE exposure, regardless of pre-GICE mental well-being.

"I felt like a freak when I would go to the doctor": Investigating healthcare experiences across the lifespan among older LGBT and transgender/gender diverse adults

In the past several decades, the United States has enacted civil rights legislation protecting lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations from discrimination, including enacting proactive healthcare laws such as the Affordable Care Act. However, given today's divisive politics, LGBTQ people's access to appropriate and respectful health care is precarious. This study explored the disconnections from and connections to health care and the respective health effects among two self-identified groups: i) older LGBT adults and ii) transgender and gender-diverse (TG/GD) adults. Using a life course perspective, qualitative data from 17 older LGBT and TG/GD participants were analyzed. Thematic and content analyses indicated that despite progress made, discrimination and prejudice in obtaining health care persist, particularly among TG/GD people of color. The results highlight the ongoing challenges LGBTQ populations face as they risk being denied care by healthcare providers and disconnected from the healthcare system.

White American transgender adults' retrospective reports on the social and contextual aspects of their gender identity development

A growing body of research has attended to the experiences of transgender and gender non-conforming (TGN) youth's gender identity development. However, practical and ethical concerns have impeded our ability to understand the experiences of TGN youth. Thus, the aim of this study was to utilize one-on-one semi-structured interviews to explore White American TGN adults' (N = 15) retrospective accounts of their gender identity development in childhood and adolescence. Findings demonstrate considerable heterogeneity in TGN adults' retrospective accounts of their gender identity development. However, TGN adults consistently highlighted the role of social (e.g. friends, family and teachers) and contextual (e.g. online, offline, educational and geographical) factors in their gender identity journeys. This study provides new insight into the role of social and contextual factors in TGN adults' retrospective accounts of their gender identity development, demonstrating the importance of continuing to examine these factors in gender diversity research.

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

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

Navigating access to medical gender affirmation in Tasmania, Australia: an exploratory study

Background: Gender affirmation through hormone replacement therapies and surgery can significantly improve the health and wellbeing of some transgender, nonbinary, and gender diverse people. Despite the well-documented benefits of gender affirming care, barriers persist for many trans and gender diverse people, particularly those in rural areas. Aims: This exploratory study aimed to identify the barriers trans and gender diverse people faced when seeking to medically affirm their gender in the rural state of Tasmania, Australia. Methods: This article draws on qualitative data from a mixed-methods online survey of 84 trans and gender diverse Tasmanians aged 18-70. Results: Participants identified financial and geographical barriers, discrimination, and medical gatekeeping as the three key factors that prevented or delayed their gender affirmation. Conclusion: Costly services that require multiple referrals to access limit trans and gender diverse patients' options, impacting their mental health and wellbeing. Gender affirmation on the basis of informed consent would reduce unnecessary medical gatekeeping and improve trans and gender diverse health and wellbeing.

The complexities of trans women's access to healthcare in South Africa: moving health systems beyond the gender binary towards gender equity

BACKGROUND

Public health research highlights the influence of socio-political biases shaping obstacles to fair healthcare access based on gender. South Africa has shown commitment to resolving gender imbalances in healthcare, historically emphasizing cisgender women's challenges. However, research gaps exist in exploring how public health systems perpetuate disparities among gender-diverse persons, like trans women, who face exclusion due to their deviation from cisgender norms in healthcare. Critical, intersectionality-informed health research carries the potential to reveal the diversity of gendered healthcare experiences and expose the systems and processes that marginalize trans patients.

METHODS

This study adopts a critical trans politics perspective to explore the socio-political forces limiting South African trans women's access to public healthcare. Using a critical narrative approach, the research asks: 1) What narratives do South African trans women share about their experiences in health systems? 2) What gendered societal structures, practices, and norms enable or hinder their inclusion in health systems? Over a period of two months in 2022, five South African adult trans women between the ages of 22 and 30 participated in 60 to 90-min long, semi-structured individual, telephonic interviews, focusing on participants' subjective experiences in healthcare.

RESULTS

Trans women's narratives unveiled a culture of medical genderism in South African public healthcare, discriminating against patients whose gender misaligns with societal norms. This culture is represented by the trans women's experiences of their identities being structurally stigmatized and delegitimized when seeking healthcare, reflected in institutional policies, practices, and protocols consistently disregarding and misgendering them. Trans women's systemic erasure was illustrated by the restricted professional knowledge, availability, and adoption of gender-affirming healthcare in a ciscentric public healthcare system prioritizing cisgender needs. The intersection of gender, race, and class dynamics compounded the obstacles faced in accessing healthcare.

CONCLUSIONS

This inquiry underscores the structural hurdles trans women face when accessing suitable public healthcare. It introduces a gender equity framework for trans inclusive healthcare, outlining implications for research, theory, policy, and practice. Toward the goal of embracing complexity and diversity, this framework, for example, promotes the rigorous absorption of trans persons and their healthcare experiences in gender-responsive programming, and encourages the development of a comprehensive understanding of gender equity from an intersectional perspective incorporating the unique needs and rights of trans healthcare seekers. The framework also offers practical guidance for cultivating health systems attuned to gender diversity (such as addressing medical genderism and recognizing the broad spectrum of identity at a policy level).

A Review of Patient Experiences and Provider Education to Improve Transgender Health Inequities in the USA

Transgender individuals are an underserved, vulnerable population. They face many inequities including barriers in both accessing and receiving adequate healthcare. These inequities are proposed here to be rooted in a lack of education about transgender people and their experiences. We begin by exploring the existing transgender healthcare research carried out in the USA, examining client experiences, provider education and attitudes, and the barriers transgender people face to obtaining proper healthcare. Secondly, we look at the previous research on educational interventions implemented with medical students and practitioners in the USA to enhance knowledge about transgender people, and increase sensitivity and awareness, while also increasing the level of comfort in working with these clients. The limitations in these fields of study are discussed in order to understand how to better serve transgender clients in the USA. We will do this through a narrative review to determine evidence-based best practices for educational intervention, uncovering gaps in the literature and highlighting where to focus in future work for researchers and practitioners.

The use of gender-neutral language in maternity settings: a narrative literature review

Background/Aims

Midwives are vital healthcare professionals that are autonomous and passionate specialists on women, pregnancy, birthing and families. Staying up to date with contemporary issues enhances their ability to provide high-quality evidence-based care. One aspect of maternal care that is changing is the use of gender-neutral language. The aim of this review was to examine the use of gender-neutral language in maternity settings and collate the literature to expose any knowledge gaps.

Methods

A narrative literature review was conducted, using primary research and literature reviews from the Cochrane Library, CINAHL and MEDLINE databases. A total of 106 articles were included.

Results

Data analysis yielded four themes: etymology and the origins of language in maternity, the effects of language in maternity, attitudes, and social media and language. The literature identified the perspective of the lesbian, gay, bisexual, transgender, intersex, queer or questioning, asexual and other sexually or gender diverse population who have accessed maternity and childcare services. Not all literature was maternity specific, but provided insight into how to improve maternity services.

Conclusions

It is recommended that education be provided for healthcare professionals when working with the LGBTIQA+ community. Updating paperwork and policies at a structural level will have a vast impact holistically on LGBTIQA+ maternity consumers.

Cervicovaginal and anal self-sampling for HPV testing in a transgender and gender diverse population assigned female at birth: comfort, difficulty, and willingness to use

Background

Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face numerous barriers to preventive care, including for HPV and cervical cancer screening. Self-sampling options may expand access to HPV testing for TGD people AFAB.

Methods

We recruited TGD individuals AFAB to collect cervicovaginal and anal specimens at-home using self-sampling for HPV testing, and individuals reported their perceptions of self-sampling. Associations between demographic and health characteristics and each of comfort of use, ease of use, and willingness to use self-sampling were estimated using robust Poisson regression.

Results

The majority of the 101 participants who completed the study reported that the cervicovaginal self-swab was not uncomfortable (68.3%) and not difficult to use (86.1%), and nearly all (96.0%) were willing to use the swab in the future. Fewer participants found the anal swab to not be uncomfortable (47.5%), but most participants still found the anal swab to not be difficult to use (70.2%) and were willing to use the swab in the future (89.1%). Participants were more willing to use either swab if they had not seen a medical professional in the past year. About 70% of participants who reported negative experiences with either self-swab were still willing to use that swab in the future.

Conclusions

TGD AFAB individuals were willing to use and preferred self-sampling methods for cervicovaginal and anal HPV testing. Developing clinically approved self-sampling options for cancer screening could expand access to HPV screening for TGD AFAB populations.

Peer-based interventions to support transgender and gender diverse people's health and healthcare access: A scoping review

Background: Pervasive health and healthcare disparities experienced by transgender (trans) and gender diverse (TGD) people require innovative solutions. Peer-based interventions may address disparities, and are an approach endorsed by TGD communities. However, the scope of the literature examining peer-based interventions to address health and healthcare access inclusive of TGD people is uncharted. Aim: This scoping review aimed to understand the extent of the literature about peer-based interventions conducted with and/or inclusive of TGD populations; specifically, study participants (e.g. sociodemographics), study designs/outcomes, intervention components (e.g. facilitator characteristics), and intervention effectiveness. Methods: Underpinned by Arksey and O'Malley's framework: (1) identifying the research question; (2) identifying studies; (3) study selection; (4) charting data; and (5) collating, summarizing, and reporting results, eligible studies were identified, charted, and thematically analyzed. Databases (e.g. ProQuest) and snowball searching were utilized to identify peer-reviewed literature published within 15 years of February 2023. Extracted data included overarching study characteristics (e.g. author[s]), methodological characteristics (e.g. type of research), intervention characteristics (e.g. delivery modality), and study findings. Results: Thirty-six eligible studies documented in 38 peer-reviewed articles detailing 40 unique peer-based interventions were identified. Forty-four percent (n = 16/36) of studies took place in United States (U.S.) urban centers. Over half (n = 23/40, 58%) focused exclusively on TGD people, nearly three-quarters of which (n = 17/23, 74%) focused exclusively on trans women/transfeminine people. Ninety-two percent (n = 33/36) included quantitative methods, of which 30% (n = 10/33) were randomized controlled trials. HIV was a primary focus (n = 30/36, 83.3%). Few interventions discussed promotion of gender affirmation for TGD participants. Most studies showed positive impacts of peer-based intervention. Discussion: Although promising in their effectiveness, limited peer-based interventions have been developed and/or evaluated that are inclusive of gender-diverse TGD people (e.g. trans men and nonbinary people). Studies are urgently need that expand this literature beyond HIV to address holistic needs and healthcare barriers among TGD communities.

Models of Gender Dysphoria Using Social Media Data for Use in Technology-Delivered Interventions: Machine Learning and Natural Language Processing Validation Study

BACKGROUND

The optimal treatment for gender dysphoria is medical intervention, but many transgender and nonbinary people face significant treatment barriers when seeking help for gender dysphoria. When untreated, gender dysphoria is associated with depression, anxiety, suicidality, and substance misuse. Technology-delivered interventions for transgender and nonbinary people can be used discretely, safely, and flexibly, thereby reducing treatment barriers and increasing access to psychological interventions to manage distress that accompanies gender dysphoria. Technology-delivered interventions are beginning to incorporate machine learning (ML) and natural language processing (NLP) to automate intervention components and tailor intervention content. A critical step in using ML and NLP in technology-delivered interventions is demonstrating how accurately these methods model clinical constructs.

OBJECTIVE

This study aimed to determine the preliminary effectiveness of modeling gender dysphoria with ML and NLP, using transgender and nonbinary people's social media data.

METHODS

Overall, 6 ML models and 949 NLP-generated independent variables were used to model gender dysphoria from the text data of 1573 Reddit (Reddit Inc) posts created on transgender- and nonbinary-specific web-based forums. After developing a codebook grounded in clinical science, a research team of clinicians and students experienced in working with transgender and nonbinary clients used qualitative content analysis to determine whether gender dysphoria was present in each Reddit post (ie, the dependent variable). NLP (eg, n-grams, Linguistic Inquiry and Word Count, word embedding, sentiment, and transfer learning) was used to transform the linguistic content of each post into predictors for ML algorithms. A k-fold cross-validation was performed. Hyperparameters were tuned with random search. Feature selection was performed to demonstrate the relative importance of each NLP-generated independent variable in predicting gender dysphoria. Misclassified posts were analyzed to improve future modeling of gender dysphoria.

RESULTS

Results indicated that a supervised ML algorithm (ie, optimized extreme gradient boosting [XGBoost]) modeled gender dysphoria with a high degree of accuracy (0.84), precision (0.83), and speed (1.23 seconds). Of the NLP-generated independent variables, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) clinical keywords (eg, dysphoria and disorder) were most predictive of gender dysphoria. Misclassifications of gender dysphoria were common in posts that expressed uncertainty, featured a stressful experience unrelated to gender dysphoria, were incorrectly coded, expressed insufficient linguistic markers of gender dysphoria, described past experiences of gender dysphoria, showed evidence of identity exploration, expressed aspects of human sexuality unrelated to gender dysphoria, described socially based gender dysphoria, expressed strong affective or cognitive reactions unrelated to gender dysphoria, or discussed body image.

CONCLUSIONS

Findings suggest that ML- and NLP-based models of gender dysphoria have significant potential to be integrated into technology-delivered interventions. The results contribute to the growing evidence on the importance of incorporating ML and NLP designs in clinical science, especially when studying marginalized populations.

Caring for nonbinary patients

ABSTRACT

Nonbinary is an umbrella term that encompasses any person whose gender identity is outside the binary construct of man or woman . An estimated 1.2 million people in the United States identify as nonbinary, a number that most likely will continue to increase as the visibility of people who live outside binary gender increases in our society. Healthcare providers are likely to encounter nonbinary patients but may lack confidence in treating these patients appropriately. This article describes terminology, concepts, and suggestions for clinicians to provide basic respectful and competent care for nonbinary patients.

Impact of a Virtual Patient Simulation on Nursing Students' Attitudes of Transgender Care

BACKGROUND

Transgender individuals experience considerable prejudice and bias, creating barriers to health care.

PURPOSE

The purpose of this study was to determine the effect of a virtual patient simulation scenario of caring for a transgender adult on nursing students' attitudes and beliefs about transgender people.

METHODS

A validated 29-item instrument developed to assess an individual's view of transgender identity was administered in a pre-/posttest nonequivalent-groups design to junior- and senior-level nursing students.

RESULTS

Statistically significant differences were found between the control and treatment groups for the subscale human value.

CONCLUSIONS

Findings support experiential learning in nursing as an effective tool in teaching cultural competence and sensitivity when caring for transgender patients. Attitudes and beliefs of senior nursing students and junior nursing students toward transgender individuals differed, with senior students being more receptive.

Provider perceptions of barriers and facilitators to care in eating disorder treatment for transgender and gender diverse patients: a qualitative study

BACKGROUND

The prevalence of eating disorders is higher in transgender and non-binary compared to cisgender people. Gender diverse people who seek eating disorder treatment often report struggling to find affirming and inclusive treatment from healthcare clinicians. We sought to understand eating disorder care clinicians' perceptions of facilitators of and barriers to effective eating disorder treatment for transgender and gender diverse patients.

METHODS

In 2022, nineteen US-based licensed mental health clinicians who specialized in eating disorder treatment participated in semi-structured interviews. We used inductive thematic analysis to identify themes around perceptions and knowledge of facilitators and barriers to care for transgender and gender diverse patients diagnosed with eating disorders.

RESULTS

Two broad themes were identified: (1) factors affecting access to care; and (2) factors affecting care while in treatment. Within the first theme, the following subthemes were found: stigmatization, family support, financial factors, gendered clinics, scarcity of gender-competent care, and religious communities. Within the second theme, prominent subthemes included discrimination and microaggressions, provider lived experience and education, other patients and parents, institutions of higher education, family-centered care, gendered-centered care, and traditional therapeutic techniques.

CONCLUSION

Many barriers and facilitators have potential to be improved upon, especially those caused by clinicians' lack of knowledge or attitudes towards gender minority patients in treatment. Future research is needed to identify how provider-driven barriers manifest and how they can be improved upon to better patient care experiences.

Mapping transgender policies in the US 2017-2021: The role of geography and implications for health equity

Transgender individuals globally face varying policy contexts that can influence their health. In the United States (US), a patchwork of exclusionary and inclusive policies exists, creating potentially different social and political contexts that shape transgender health depending on the state. In this article, we consider how recent legislation introduced in US states focused on transgender people may be a political determinant of health and affect health equity goals. To advance this aim, we employed the perspective of legal epidemiology to systematically search a US legal database (Westlaw) for policies focused on transgender individuals proposed between January of 2017 and September of 2021.698 policies were analyzed as affirming or exclusionary of transgender identities and categorized by content. We calculated a ratio of affirming versus exclusionary bills to create "exclusionary density" and "affirming density" measures. Those measures were used to calculate an inclusivity score and corresponding maps of inclusivity and exclusionary contexts by US state. Exclusionary and affirming density measures showed deeply polarized policy responses to transgender individuals depending on US state. Further, we observed differences in magnitude regarding the laws being proposed. Exclusionary laws largely focused on criminalization while inclusionary laws focused on representation in government agencies. These findings highlight that transgender individuals in the US can experience vastly different political contexts depending on where they live.

Incorporating Intersectionality in Neuropsychology: Moving the Discipline Forward

OBJECTIVE

Intersectionality is the interface between a person's identities in relation to social systems and institutional discrimination. The concept has generated much interest in psychology for understanding societal inequities and providing culturally informed services to minoritized patients but has yet to be incorporated in clinical neuropsychology. This omission is unfortunate as it is argued that appreciating the impact of institutional discrimination on minoritized groups can enhance our understanding of brain organization and functioning and bolster access to competent neuropsychological services to minoritized patients. The purpose of this article is to illustrate how intersectionality is germane to the discipline of clinical neuropsychology and to make recommendations for infusing it into the practice.

METHOD

Theories and findings in cultural neuroscience are summarized to provide a theoretical background for understanding how the environment can impact brain development and organization. The literature on disparities in education, economics, and health disparities between Whites and minoritized groups was reviewed for institutional biases that place minoritized groups at a disadvantage. These topics were selected due to their known impact on brain organization and cognition. This was followed by a similar review for access to competent neuropsychological assessments for minoritized patients.

RESULTS

There is a confluence of institutional discriminatory processes that contribute to disparities in education attainment, economic status, health disparities, and accessibility to culturally informed neuropsychological services. Perceived discrimination has significant health and cognitive ramifications.

CONCLUSIONS

Intersectionality is germane to appreciating brain functioning and providing competent services to minoritized patients. Recommendations were made to incorporate intersectionality in clinical neuropsychology.

Liver function in transgender persons: Challenges in the COVID-19 era

Transgender persons constitute a non-negligible percentage of the general population. Physical gender-transitioning in trans persons is mainly achieved with hormonal cross-sex therapy and sex reassignment surgeries that aim to align bodily appearance with gender identity. Hormonal treatment acts via suppressing the secretion of the endogenous sex hormones and replacing them with the hormones of the desired sex. The administration of testosterone is the typical masculinizing treatment in trans men, whilst trans women are routinely treated with estradiol agents in combination with anti-androgens or gonadotrophin-releasing hormone agonists if testes are present. Exogenous androgenic steroids, estradiol agents, and anti-androgens have been implicated in a series of hepatotoxic effects. Thus, liver integrity is a major concern with the long-term administration of cross-sex therapy. Hepatic tissue is susceptible to coronavirus disease 19 (COVID-19) through various pathophysiological mechanisms. Special consideration should be paid to minimize the risk of hepatic damage from the potential cumulative effect of COVID-19 and gender-affirming treatment in transgender patients. Appropriate care is significant, with continuous laboratory monitoring, clinical observation and, if needed, specific treatment, especially in severe cases of infection and in persons with additional liver pathologies. The pandemic can be an opportunity to provide equal access to care for all and increase the resilience of the transgender population.

Rural Perspectives on Health Services for Transgender and Gender Diverse Youth

As the world grows more diverse, physicians and public health practitioners must become adept at providing care to everyone, including people who identify as transgender or gender diverse (TGD). Although this population is growing in all age demographics, there is a large increase in young TGD individuals who require pediatric health care providers to improve their practices. While a few comprehensive care clinics have been established to serve the TGD community, they are mostly located in urban areas. In addition to the unique barriers faced by rural TGD youth, providers must care for their patients with limited resources. In this commentary, we offer a set of recommendations to improve provider education, build connections between the health system and community, address the fragmentation of health services in rural areas and improve the transition from pediatric to adult health care.

The Intersection of Stress, Health, and Health Care Opportunities for Appalachian Transgender and Nonbinary People: An Interpretative Phenomenological Analysis

Transgender or nonbinary (TNB) individuals in the United States South experience higher rates of physical and mental health disparities when compared to their cisgender counterparts. Societal, interpersonal, and individual stigmas contribute to these disparities by increasing the levels of stress in the TNB population, which is a primary factor in higher morbidity and mortality. However, there is a paucity of research examining the impact of these stigmas on health through the lived experiences of TNB people living in Appalachia. An interpretive phenomenological analysis (IPA) research design was used to collect and analyze semi-structured interviews with TNB individuals living in Appalachia. Transcribed interviews were analyzed repeatedly by two analysts to identify emergent themes which focused on understanding an individual's lived experiences through interpretation. Ten participants from four Appalachian states within three Appalachian sub-regions participated in this study. Three shared healthcare themes were identified: experiences of stigma related to gender, the impact of stigma on personal wellbeing and perception of health, and the need for affirming TNB healthcare services. Respondents noted that chronic stress factors such as continual and compounding experiences of stigma and discrimination, stemming from religion or lack of affirming providers, negatively impacted their health. TNB individuals living in Appalachia experience chronic societal, interpersonal, and individual stressors that negatively impact their health. By addressing the stigmas, public health leaders, policymakers, and providers can improve access to health care and the health and quality of life of Appalachian TNB people.

"I Don't Want to Spend the Rest of my Life Only Going to a Gender Wellness Clinic": Healthcare Experiences of Patients of a Comprehensive Transgender Clinic

BACKGROUND

Transgender individuals are less likely to have had a primary care visit in the last year than cisgender individuals. While the importance of multidisciplinary clinics for transgender care has been established, little is known about the healthcare experiences of transgender patients with these clinics.

OBJECTIVE

To describe how patients experience transgender clinics and how these experiences compare to those experiences in other settings.

PARTICIPANTS

Twenty-one adult patients of a gender health program.

DESIGN AND APPROACH

Semi-structured interviews of transgender patients. The interviews focused on two domains: healthcare experiences and relationships with healthcare providers.

KEY RESULTS

Overall, transgender patients expressed a need for healthcare services, particularly for primary care, that are partially met by the comprehensive care clinic model. Limitations in access included the lack of willing providers, where the patients live, and long wait times for appointments. Participants recounted a range of experiences, both positive and negative, with providers outside of the transgender clinic, but only positive experiences to share about providers from the transgender clinic.

CONCLUSION

Outside specialty transgender settings, many patients had negative experiences with providers who were unwilling or unable to provide care. This study speaks to the need for primary care providers who can and will treat transgender patients, as well as the need for healthcare spaces that feel safe to transgender patents.

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.

"I'm coming out!": An autoethnographic situation of sel/f/ves within queer fat chronically Ill identity

In this article, we (two fat, white, queer, nonbinary, chronically ill critical social work scholars) explore the parallel processes of coming out as fat and coming out as other identities (queer, femme, neurodivergent, nonbinary, chronically ill, disabled). We begin by reviewing literature from queer theories, crip theory, and fat studies, addressing concepts of "coming out" and identity. Next, taking an identity-centered autoethnographic and autoarchaeological approach, we explore how the processes in coming out as fat-growing critical consciousness, positive social identity reclamation, community belonging-mirrored other coming out processes, fostering resilience in our lives. We perform this reflection on sense(s) of self within a queer critical intersectional approach, as we individually and collectively examine how our fat identities are situated within our gender, racial, class, ability, health, and sexual orientation contexts. We interrogate how these identities of fatness and beyond, both privileged and oppressed, interplay in our personal, professional, and health-related experiences, and interactions with others. Finally, building off of the theoretical work proposed by Hunger, Major, and Blodorn (2015), we integrate concepts of critical consciousness, positive social identity, and community connectedness into the social identity threat model (as applied to weight stigma), hypothesizing how these potential positive outcomes of "coming out" may moderate the relationship between the psychological stress associated with marginalized identity and the adverse physical and mental health outcomes commonly associated with oppression and minority stress.

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.

“We Are Doing the Absolute Most That We Can, and No One Is Listening”: Barriers and Facilitators to Health Literacy within Transgender and Nonbinary Communities

Transgender and nonbinary (TNB) individuals face disparities in nearly every aspect of health. One factor associated with poor health outcomes in other marginalized populations is health literacy, yet no identified studies examine health literacy in TNB samples. Moreover, most health literacy frameworks focus primarily on the capacities of individual patients to understand and use healthcare information, with little attention given to provider literacy and environmental factors. In partnership with a statewide LGBTQ advocacy organization, we recruited 46 transgender and nonbinary individuals to participate in seven focus groups conducted in urban, suburban, and rural locations throughout Colorado. TNB participants consistently engaged in efforts to increase their own health literacy and that of their medical providers yet faced multiple barriers to improve care. Difficulty identifying and physically reaching care, insurance and out-of-pocket expenses, negative experiences with healthcare providers and staff, provider incompetence, discriminatory and oppressive practices, and exclusionary forms and processes emerged as barriers to enacted health literacy among participants. Conversely, facilitators of enacted healthcare literacy included positive experiences with healthcare providers and staff, and inclusive forms and processes.

"The Light at the End of the Tunnel": Experiences of LGBTQ+ Adults in Portuguese Healthcare

This work analyses experiences of LGBTQ+ people accessing healthcare in Portugal. A total of 32 semi-structured interviews were conducted with queer adults (18-59 years old). The thematic analysis and thematic networks brought to light how structural cis-heteronorms are compliant with the maintenance of invisibility regarding sexual and gender diversity. As a consequence, experiences of direct and indirect discrimination show us how crucial it is to have well prepared healthcare providers, capable of embracing diversity and creating safe spaces that allow us to shorten the path between Portugal's progressive legal frame and the people lived experiences.

Exploring the Experiences of Transgender and Gender Diverse Adults in Accessing a Trans Knowledgeable Primary Care Physician

Transgender and gender diverse individuals face a variety of barriers when attempting to access healthcare, from discrimination to lack of access to lack of knowledgeable providers. Using data from the 2015 United States Trans Survey (N = 27,715), this study looks at the differences within the TGD population regarding having seen a doctor in the past year, having a primary care provider, and having a primary care provider who is knowledgeable about trans health. Logistic regressions indicate that even within an all transgender and gender diverse sample, a variety of identities and experiences are related to increased or decreased likelihood of each of these outcomes, with significant differences across gender, race/ethnicity, age, sexual orientation, disability status, educational attainment, annual income, disability status, religiosity, military status, overall health, housing status, and insurance coverage. Not only should there be an effort to support transgender and gender diverse individuals in accessing care, but there is a clearly indicated need for additional education for healthcare providers, especially those doing primary care, on how to offer knowledgeable, affirming, and intersectional care to their patients.

Health and Access to Gender-Affirming Care During COVID-19: Experiences of transmasculine individuals and men assigned female sex at birth

Since the onset of the COVID-19 pandemic, global research has suggested that the pandemic has negatively affected lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) populations, including by limiting health care access. There is little research on the impact of COVID-19 among transmasculine persons and men assigned female sex at birth (AFAB) in the United States, who face unique health care challenges outside of the pandemic context. Between May and June of 2020, 20 transmasculine individuals and AFAB men who have sex with men participated in semi-structured interviews about their experiences during the early months of the COVID-19 pandemic. Participants were asked how the pandemic affected their access to health care, overall health, and well-being. Interviews were analyzed using an inductive, thematic approach. Participants reported reduced access to in-person health care, which in some cases meant overdue hormone-related bloodwork and unmet health care needs. Most participants reported that they were able to maintain their testosterone regimen, although some were concerned about future access, citing anxiety about potential shortages. Three participants reported canceled or deferred gender-affirming procedures, which they were uncertain would be rescheduled soon. Participants generally reported that the expansion of telehealth improved access to care, particularly for gender-affirming psychotherapy that was otherwise inaccessible or inconvenient prior to the pandemic. Other salient themes include the pandemic's impact on health behaviors and daily routines. Although the COVID-19 pandemic created new challenges for maintaining health, it also expanded access to gender-affirming health care, largely through the expansion of telehealth. Our findings provide new insights for supporting the health of transmasculine individuals and AFAB men.

New horizons in trans and non-binary health care: Bridging identity affirmation with chronicity management in sexual and reproductive services

BACKGROUND

Transgender and non-binary people experience erasure, stigma, and discrimination in sexual and reproductive health care. Previous research shows worse sexual and reproductive health outcomes and higher rates of chronicity for trans and non-binary populations as compared to cisgender populations. Historically such outcomes have been framed as separate issues.

AIMS

To describe methodological approaches for exploring gaps in the sexual and reproductive health care of transgender and non-binary people, and explore intersections between chronic disease management and gender-affirming care.

METHODS

We critically reviewed methods for studying sexual and reproductive care and chronic condition management among trans and non-binary populations. We focus on two themes: unmet needs and response strategies.

RESULTS

We summarize findings and opportunities in existing research about service needs in trans and non-binary care. Key barriers to effective sexual and reproductive care for trans and non-binary people include persistent medical myths about trans people and bodies, siloization of different domains of health and associated services, lack of research on how chronic disease treatments interact with transition related care, and lack of active communication between providers and patients about individual care needs and goals.

DISCUSSION

We recommend methodologically diverse research with trans and non-binary populations capturing: (1) erasure, stigma, and discrimination in sexual and reproductive health care settings; (2) individual, interpersonal, and structural factors catalyzing chronicity; and (3) the impact of sexual and reproductive health disparities on chronic disease outcomes.

Listening to Transgender Patients and Their Providers in Non-Metropolitan Spaces: Needs, Gaps, and Patient-Provider Discrepancies

Trans and gender non-conforming (TGNC) patients need better care; providers need TGNC focused medical trainings. TGNC health conferences can help, yet these events occur mostly in urban centers. Meanwhile, patients in non-metropolitan areas often face significant discrimination and notably poor access to TGNC care. This study explores the ongoing needs of TGNC patients and their providers following a one-day TGNC health conference in a small town in the American Midwest. Exploratory semi-structured interviews were used to gather in-depth information from TGNC conference attendees (N = 25). Theme analysis methods were used to identify areas of need for future trainings. Providers reported that they needed more exposure to TGNC patients, judgement-free opportunities to learn the basics about TGNC care, and ongoing trainings integrated into their medical school and ongoing education credits. Patients needed better access to care, more informed providers, and safer clinics. They cited lack of specialty care (e.g., mental health, surgery) as particularly problematic in a non-metropolitan setting. TGNC patients, and their providers in non-metropolitan areas, urgently need support. Patients lack specialized care and often possess greater knowledge than their health care teams; providers, in these areas, lack opportunities to work with patients and stay up to date on treatments.

Ethical and culturally competent care of transgender patients: A scoping review

BACKGROUND

Transgender individuals experience discrimination, stigmatization, and unethical and insensitive attitudes in healthcare settings. Therefore, healthcare professionals must be knowledgeable about the ways to deliver ethical and culturally competent care.

ETHICAL CONSIDERATIONS

No formal ethical approval was required.

AIM

To synthesize the literature and identify gaps about approaches to the provision of ethical and culturally competent care to transgender populations.

DESIGN

A Scoping Review.

LITERATURE SEARCH

Literature was searched within CINAHL, Science Direct, PubMed, Google Scholar, EMBASE, and Scopus databases using indexed keywords such as "transgender," "gender non-conforming," "ethically sensitive care," and "culturally sensitive care." In total, 30 articles, which included transgender patients and their families and nurses, doctors, and health professionals who provided care to transgender patients, were selected for review. Data were extracted and synthesized using tabular and narrative summaries and thematic synthesis.

FINDINGS

Of 30 articles, 23 were discussion papers, 5 research articles, and 1 each case study and an integrative review. This indicates an apparent dearth of literature about ethical and culturally sensitive care of transgender individuals. The review identified that healthcare professionals should educate themselves about sensitive issues, become more self-aware, put transgender individual in charge during care interactions, and adhere to the principles of advocacy, confidentiality, autonomy, respect, and disclosure.

CONCLUSIONS

The review identified broad approaches for the provision of ethical and culturally competent care. The identified approaches could be used as the baseline, and further research is warranted to develop and assess organizational and individual-level approaches.

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.

[Self-assessment of healthcare workers regarding the management of trans people in a university hospital]

INTRODUCTION

Trans people face more barriers when seeking healthcare than the cisgender population probably due to a lack of knowledge, education and comfort of healthcare workers. The purpose of this study was to assess the knowledge and comfort felt by healthcare professionals in managing trans people in a French university hospital.

METHODS

A self-questionnaire was emailed to healthcare professionals working in departments usually involved in the care of trans people in a French university hospital "not specialized" in medical and surgical gender transition. The questionnaire included demographic questions and Likert scales regarding their knowledge and comfort in taking care of trans people. Responses on the 7-point Likert scales were categorized into "low", "medium" and "high" groups, and responses on the 5-point Likert scales were categorized into "in favour", "neutral" and "against" groups.

RESULTS

One hundred and two (29%) healthcare professionals answered the questionnaire. Half worked in surgical departments (urology, plastic surgery, gynecology), 24% worked in medical departments (endocrinology, reproductive medicine, cytogenetics) and 26% worked in psychiatry. The majority (60.3%) rated their level of knowledge as "low" and 39.7% as "medium". Sixteen percent rated their level of comfort in managing trans people as "low", 72.5% as "medium" and 11.5% as "high". A majority (77.5%) were in favor of having the costs of gender transition care covered by the national health insurance system, 16.4% were neutral and 6% were against this idea. Feelings about surgical and hormonal gender transition were overwhelmingly (96.4%) in favour or neutral and 91% were willing to get more training and education to manage trans people.

CONCLUSION

The lack of comfort felt by healthcare professionals in university hospital in managing trans people seems to be related to a lack of knowledge and training in that field and not to a disagreement with the need of transgender healthcare.

LEVEL OF EVIDENCE

3.

Transgender Care and the COVID-19 Pandemic: Exploring the Initiation and Continuation of Transgender Care In-Person and Through Telehealth

Gender-affirming care is essential to the health and wellbeing of transgender and nonbinary people. The COVID-19 pandemic has the potential to disrupt transgender care. This study explores transgender care before and during the onset of the pandemic using patient data from 10 family planning clinics in Arkansas, Kansas, Missouri, and Oklahoma. No significant differences were observed in the proportion of transgender care visits pre- or during the pandemic. However, we did find a significantly larger proportion of new transgender patient visits and significantly smaller proportion of established patient visits during the pandemic, with nearly half delivered through telehealth care.

"A center for trans women where they help you": Resource needs of the immigrant Latinx transgender community

Background

Immigrant Latinx transgender people often migrate to the United States because of a desire for increased safety and more opportunities. However, after migrating to the United States, immigrant Latinx transgender people often struggle to access basic needs, including health care, jobs, and stable finances. These struggles are exacerbated for undocumented immigrant Latinx transgender people. There is a gap in the literature regarding needed resources for immigrant Latinx transgender community members living in the United States.

Aims

Utilizing a critical intersectionality framework, the aim of the present study was to investigate the resource needs of immigrant Latinx transgender community members living in the United States.

Methods

A community sample of 18 immigrant Latinx transgender people living in a large metropolitan city in Florida participated in individual semi-structured interviews to explore their community resource needs.

Results

Thematic analysis revealed five themes related to resources that participants needed including: 1) Transgender healthcare/resources, 2) Public education, 3) Financial aid resources, 4) Homelessness resources, and 5) Addictions care. Two resource need-related themes were identified that pertain specifically to undocumented immigrant Latinx transgender people, including: 1) Documentation papers for access, and 2) Legal aid.

Conclusions

Findings suggest that immigrant Latinx transgender community members in this study provided guidance about broad resources needed to enhance their wellness and safety, and promote liberation of community members. Participants' resource needs suggest the importance of policy and structural level changes from institutions with power that consider and enhance the wellness of immigrant Latinx transgender people. Findings also suggest the need for more tailored interventions and case work to better support immigrant Latinx transgender people.