Models of Care and Team Activities in the Delivery of Transgender Primary Care: An Ontario Case Study

Collectives for Care: Perspectives of Providers and Community Members in Transgender Health Care in a Southern U.S. City

Affirming and accessible health care may improve health outcomes for trans individuals in the U.S. We explored strategies to improve affirming care for trans individuals from the perspectives of providers and transgender and non-binary community members. Forty members of a collective group of gender-affirming providers (GAP) in the southern U.S. were recruited to participate in a brief online survey. A graphical LASSO undirected network analysis approach visualized associations across outcomes and explanatory variables. Multinomial ordered (or logistic, for binary outcomes) models explored associations between a common set of explanatory variables and outcomes. Strong partial correlations (network) and statistically significant explanatory variables (ordinal and logistic models) were identified. Additionally, we conducted three focus groups (FGs) audio-recorded over Zoom with 11 community members. Four study team members analyzed the transcripts using content analyses. Survey results indicated that higher frequency of attendance at monthly provider meetings, additional training, and provision of training and consultation were associated with greater perceived competence among GAP members. To improve services, FG participants suggested treating patients as experts, increasing diversity and representation among providers, and expanding the GAP group. These results highlight the critical need to design and implement community-identified interventions to improve gender-affirming services and enhance provider training.

Primary care in Northern Ontario for transgender people in the context of the COVID-19 pandemic: A qualitative secondary analysis

PURPOSE

To examine changes to primary care practice for transgender clients resulting from government mandated public health measures in response to COVID-19 in Northern Ontario.

DESIGN

Secondary analysis of qualitative data using interview transcripts from a dataset that included 15 interviews conducted between October 2020 and April 2021.

METHODS

The dataset came from a convergent mixed method study exploring the delivery of primary care services to transgender individuals in Northern Ontario. Qualitative interviews with primary care practitioners including nurse practitioners, nurses, physicians, social workers, psychotherapists, and pharmacists providing care for transgender people in Northern Ontario were included in the secondary analysis.

RESULTS

Fifteen primary care practitioner providing care to transgender individuals in Northern Ontario participated in the parent study. Practitioners described their understanding of the effect of the early stages of the COVID-19 pandemic changes on their practice and the care experience for their transgender patients. Two themes were identified and described by participants: (1) a change in the delivery of care; and (2) barriers and facilitators to care.

CONCLUSIONS

Practitioners' primary care experiences in the early waves of COVID suggest the integral use of telehealth in Northern Ontario transgender care. Nurses working in advance practice and nurse practitioners are essential in providing continuity of care for their transgender clients.

CLINICAL RELEVANCE/SIGNIFICANCE

Identification of initial practice changes for the primary care of trans people will illuminate avenues for further research. The urban, rural, and remote practice settings in Northern Ontario provide an opportunity for increasing access for gender diverse people in these areas and for developing increased understanding of uptake of telemedicine practice. Nurses are integral to primary care for transgender patients in Northern Ontario.

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.

Positive patient-provider relationships among transgender and nonbinary individuals in New York City

Background: Transgender and nonbinary (TGNB) individuals have diverse health needs and may face disproportionate barriers to healthcare, including developing positive patient-provider relationships. While there is mounting evidence of gender-based stigma and discrimination in healthcare, little is known about how TGNB individuals develop positive patient-provider relationships. Aims: To examine TGNB individuals' interactions with healthcare providers and identify main characteristics of positive patient-providers relationships. Methods: We conducted semi-structured interviews with a purposive sample of 13 TGNB individuals in New York, NY. Interviews were transcribed verbatim and analyzed inductively for themes related to characteristics of positive and trusting relationships with healthcare providers. Results: Participants' mean age was 30 years (IQR = 13 years) and most participants were nonwhite (n = 12, 92%). Receiving peer referrals to specific clinics or providers helped many participants find providers perceived to be competent and created initial grounds for positive patient-provider relationships. Providers with whom participants had positive relationships commonly managed primary care and gender-affirming care and relied on a network of interdisciplinary providers for other specialized care. Providers who were positively evaluated were perceived to possess in-depth clinical knowledge on the issues they were responsible for managing, including gender-affirming interventions, particularly for TGNB patients who perceived themselves to be knowledgeable about TGNB-specific care. Provider and staff cultural competence and a TGNB-affirming clinic environment were also important, particularly early in the patient-provider relationship, and if combined with TGNB clinical competence. Discussion: Provider-focused training and education programs should combine components of TGNB clinical and cultural competence to facilitate development of positive relationships between TGNB patients and providers, thereby improving the health and wellbeing of TGNB people.

Experiences and Perceptions of Trans and Gender Non-Binary People Regarding Their Psychosocial Support Needs: A Systematic Review of the Qualitative Research Evidence

People who identify as trans and gender non-binary experience many challenges in their lives and more interest is being paid to their overall health and wellbeing. However, little is known about their experiences and perceptions regarding their distinct psychosocial needs. The aim of this systematic review is to critically evaluate and synthesize the existing research evidence relating to the unique psychological and social experiences of trans people and identify aspects that may help or hinder access to appropriate psychosocial interventions and supports. The PRISMA procedure was utilized. A search of relevant databases from January 2010 to January 2021 was undertaken. Studies were identified that involved trans people, and addressed issues related to their psychosocial needs. The search yielded 954 papers in total. Following the application of rigorous inclusion and exclusion criteria a total of 18 papers were considered suitable for the systematic review. Quality was assessed using the MMAT instrument. Following analysis, four themes were identified: (i) stigma, discrimination and marginalization (ii) trans affirmative experiences (iii) formal and informal supports, and (iv) healthcare access. The policy, education and practice development implications are highlighted and discussed. Future research opportunities have been identified that will add significantly to the body of evidence that may further the development of appropriate health interventions and supports to this population.

The integral role of nurses in primary care for transgender people: A qualitative descriptive study

AIM

To understand nursing activities, training and key supports needed to provide primary care to transgender individuals.

BACKGROUND

Discrimination, limited practitioner knowledge and a deficiency of services contribute to health care barriers for transgender individuals. Literature demonstrating how primary care services are delivered, and more specially the role of nurses in this care, is lacking.

METHODS

Qualitative description methodology and interviews were used to describe this phenomenon. Participants included nurse practitioners, registered nurses and registered practical nurses.

RESULTS

Nurses are important in providing primary care to transgender individuals. While NPs worked to full scope of practice, RNs' and RPNs' roles could be optimized. A key challenge was lack of education; however, mentorship and collaboration contributed to competency development. Ensuring the workplace provided gender-affirming care was key to a safe and inclusive environment.

CONCLUSIONS

Supporting nurses to develop capacity and work to full scope of practice can improve access to care. Ongoing opportunities for mentorship and ensuring an inclusive workplace will aid in the provision of care for this vulnerable population.

IMPLICATIONS FOR NURSING MANAGEMENT

Development of organisational policies, staff training and appropriate supports, for role optimization and team collaboration, can eliminate barriers experienced by transgender individuals.