Communicating With Patients Who Have Nonbinary Gender Identities

Factors associated with communication preferences in transgender and/or gender-diverse individuals - a survey study

INTRODUCTION

As communication should be adapted to the individual, the aim of this study was to explore possible factors related to communication preferences in transgender and/or gender-diverse individuals.

METHODS

A survey study was conducted in September 2022. Communication preferences were assessed using the CommTrans questionnaire, which included two scales: emotional resonance and gender-related communication. Additionally, we assessed gender, age, relationship status, number of self-reported minorities, health literacy, mental health, and own communication style. Analyses were conducted using multiple linear regression analyses.

RESULTS

A total of 223 individuals completed the survey, of whom 139 (58.2 %) identified as non-binary. Participants valued emotional resonance moderately high (Mean.: 70.6; SD.: 19.5) and gender-related preferences in the middle range (Mean 57.4; SD.: 27.2). As regards emotional resonance, not identifying with a minority was associated with a lower importance of doctors' response to patients emotions. Furthermore, having a self-confident communication style as a transgender and/or gender-diverse individual was related to a lower perceived importance in gender-related communication, while identifying as non-binary was related with a greater importance.

CONCLUSION

Our findings might help to expand doctors' knowledge, and thus help them to provide patient-centered care for transgender and/or gender-diverse individuals.

Bright Voice Quality and Fundamental Frequency Variation in Non-binary Speakers

OBJECTIVES

1) To investigate if vocal variation produced by assigned-female-at-birth (AFAB) non-binary people differed from vocal variation produced by cisgender (cis) participants. Cue values produced by non-binary participants were predicted to differ from those values produced by cisgender participants. 2) To determine if previous subjective assessments of bright voice quality in AFAB non-binary participants were quantifiable, and if so, if non-binary and cisgender participants differed in their voice quality production.

STUDY DESIGN

A quantitative comparative research design.

METHODS

Phonetic and statistical analyses of continuous speech samples produced by AFAB non-binary and cisgender participants. Vocal cues were mean fundamental frequency (F0) and bright voice quality, measured by cepstral peak prominence-smoothed and spectral slope, with speaker gender as the predictor.

RESULTS

At the group level, non-binary participants produced intermediate F0 values - significantly lower than the cis women's and significantly higher than the cis men's. Individually, the majority of non-binary participants produced mean F0 in this intermediate range. Non-binary participants produced significantly less negative spectral slope and higher cepstral peak prominence-smoothed, indicative of a brighter, more resonant voice quality. Individual-level results indicated that vocal training and vocal tract physiology did not fully account for the results found.

CONCLUSION

Participants' agency, particularly their motivation to alter vocal output to avoid being misgendered, has an effect on the AFAB non-binary participants' F0 production and potentially their voice quality. The majority of AFAB non-binary participants uniquely produced the cue combination of intermediate F0 and bright voice quality.

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

Describing Non-Binary People's Encounters with the Healthcare System: A Qualitative Study in Catalonia (Spain)

Non-binary people face numerous stressors in their daily lives, including personal, interpersonal, and environmental. These stressors gain strength when such individuals access healthcare services, and discrimination and cisgenderism become the main barrier to obtaining gender-affirming healthcare. This study aimed to describe the experiences of non-binary people regarding the care and medical attention received in Catalonia (Spain). A qualitative phenomenological study was conducted with 21 non-binary people recruited using snowball sampling in 2022. Data were gathered through open-ended interviews and analyzed using thematic analysis. Two main themes were identified, which were further classified into two categories each: Theme 1-This is me composed of the categories, "My Name and My Pronouns" and "One's Chosen Gender," and Theme 2-I do not exist for the health system consisting of "Uneducated Health System in Sexual Health" and "Feeling Like an Outsider for Being Non-Binary." Non-binary people face multiple stressors when accessing the healthcare services that makes them feel invisible, vulnerable, and marginalized. Further widespread implementation of person-centered care is essential to promote the relationship between non-binary people and the healthcare system. In addition, further sexual health training is required for all health professionals.

Gender Is a Spectrum: Evaluating Current and Novel Ways to Inquire About Gender Identity in the Health Care Setting

PURPOSE

The use of visuals to inquire about gender in the clinical setting has been rare. We developed a survey that included a visual spectrum to assess perceptions about the most and least inclusive ways of inquiring about gender in patients with gender dysphoria.

METHODS

The survey included a multiple-choice question (MCQ), free-response question, and a visual spectrum on which respondents were asked to select one box that best depicts their gender. The survey was administered to all patients diagnosed with gender dysphoria at our institution between April and June 2022.

RESULTS

A total of 223 of 856 patients responded. Those with more masculine gender identities selected boxes near the visual spectrum corner of "man," whereas responses were more variable for more feminine genders. The free-response question was identified by 59% of respondents as the most inclusive. The MCQ was identified as least inclusive by 70.4%. The visual spectrum was considered the most inclusive method by the majority of patients who self-identified as woman and demiwoman/demifemale. Being asked about pronouns was extremely or very important in the health care setting for 52% of respondents, but 68.6% indicated that they are rarely or sometimes asked about their pronouns in this setting.

CONCLUSIONS

The traditional MCQ format for self-identifying gender may be lacking in inclusivity and fails to represent the nuances of gender identity. Free response was considered the most inclusive way to inquire about gender among our respondents. These findings highlight the importance of formatting gender identity questionnaires to foster inclusivity for transgender patients.

Limitations and Future Directions in Sex, Sexuality, and Gender Diverse Research in Neurology

Sex, sexuality, and gender diversity is understudied and underserved in neurology. Neurology research inclusive of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual) people is limited. Existing research struggles with a paucity of neurology studies collecting sex, sexuality, and gender diverse (SSGD) data, conflation of sex and gender, lack of precision in measures, neglect of younger and older populations, nebulous benefit to community, and absent intersectionality. Future directions in SSGD neurology research include precise and community-based measurements, respect for LGBTQIA+ colleagues, and the application of minority stress models. All patients stand to benefit from research that elucidates how SSGD variables influence neurological health. ANN NEUROL 2024;95:421-431.

'I don't want to have to teach every medical provider': barriers to care among non-binary people in the Canadian healthcare system

It is well-known that trans and non-binary individuals experience worse health outcomes due to experiences of violence and discrimination. For this reason, accessible healthcare for trans and non-binary people is crucial. There is a lack of Canadian literature on the experiences of non-binary people within the healthcare system. This study sought to understand barriers to healthcare among non-binary people living in a mid-sized urban/rural region of Canada. Interviews were conducted between November 2019 to March 2020 with 12 non-binary individuals assigned female at birth, living in Waterloo Region, Ontario, Canada, as a part of a larger qualitative study exploring experiences within the community, healthcare and employment. Three broad themes were developed: erasure, barriers to access to healthcare, and assessing whether (or not) to come out. Sub-themes included institutional erasure, informational erasure, general healthcare barriers, medical transition healthcare barriers, anticipated discrimination, and assessing safety. Policy and institutional changes are needed to increase the safety and accessibility of healthcare services to non-binary individuals.

The Sun Also Rises: Tracing the evolution of humanistic values in anatomy pedagogy and research, including cadaveric acquisition practices

Anatomy has always been at the intersection of the socio-cultural and political landscape, where new ideas constantly replace older wisdom. From ancient Egyptians through the Greeks, and then the Romans, finally culminating into the European Renaissance-all the significant eras of human civilisation have left their insignia and distinct marks on the evolution of anatomical practices. Despite its utility as a tool for anatomy pedagogy and research that has proven its worth over millennia, cadaveric dissection has particularly been subject to political and social vicissitudes. A major debate about anatomical dissection lay with the ethical considerations, or its lack thereof, while acquiring corpses for demonstration in the dissection halls. From antiquity, anatomical dissection-often synonymous with medical studies-had typically been carried out on the dead bodies of executed criminals with certain laws, such as the Murder Act of 1752, facilitating such uses. Gradually, the uses of unclaimed bodies, resourced primarily from the impoverished sections of society, were also introduced. However, these body acquisition protocols often missed the crucial element of humanism and ethical considerations, while knowledge augmentation was taken as sufficient reasoning. Unfortunately, a gross disregard towards humanistic values promulgated heinous and illegal practices in acquiring corpses, including grave robbery and even murders like in the case of Burke and Hare murders of 1828. Follow-up legislation, such as the Anatomy Act of 1832, and comparable laws in other European nations were passed to curb the vile. What distils from such a historical discourse on humane values in anatomy dissection, or medical science in general, is that the growth and integration of humanism in anatomy have never been linear, but there were intermittent and, yet, significant disruptions in its timeline. For example, there were serious human rights violations in anatomical practices during the Third Reich in Germany that perpetrated the holocaust. The medical community has kept evolving and introducing new moral values and principles while using such egregious events as lessons, ultimately resulting in the Declaration of Helsinki in 1964. This article revisits the heterogeneous journey of integrating humanistic values in anatomy practice. Such humanistic traits that, like medical science, have also developed over centuries through the inputs of physicians, researchers, and philosophers-from Greece to modernity with an important stopgap at the Renaissance-are a fascinating lore that deserves to be re-envisioned through the lens of contemporary values and ethos. In parallel to human medicine, humanistic values continue to influence veterinary medicine, a welcome development, as our society condemns animal cruelty in any form. There are lessons to be learned from this historical journey of how humanism shaped many of the concepts that anatomists use now. Finally, and most importantly, it might prevent the medical community from repeating the same mistakes by cautioning against the traps that are there, and in a convoluted world where morality as such is eroding from our social fabric, will always be there. Such historical account acts as a righteous, ethical, and contextual compass to guide the existing and upcoming anatomists in discerning between light and dark, right and wrong, and roads-to be or not to be-taken.

Why do transgender individuals experience discrimination in healthcare and thereby limited access to healthcare? An interview study exploring the perspective of German transgender individuals

BACKGROUND

Transgender individuals experience limited access to healthcare. This results not least from experiences of discrimination to which they are exposed in the health system. These contribute to transgender individuals having poorer health than cis individuals, i.e. individuals whose sex assigned at birth is in line with their gender identity. It is an ethical duty to take effective measures to minimize inequalities in medical care. At best, such measures should also be assessed as appropriate from the perspective of those affected in order to be accepted and thus effective. It is therefore important to know whether measures touch on the subjectively assumed reasons for experiences of discrimination. Hence, to be able to take appropriate measures, it is important to identify the reasons that transgender individuals see as causal for their experiences of discrimination in healthcare.

METHODS

We conducted semi-structured interviews with 14 German transgender individuals and asked them about their own experiences of discrimination in healthcare and their assumptions on the reasons for discrimination. We analyzed the responses using the method of structured qualitative content analysis.

RESULTS

13 transgender individuals reported experiences of discrimination in healthcare. These emanated from different professional groups and took place in trans-specific as well as general medical settings. We were able to identify a total of 12 reasons that transgender individuals see as causal for their experiences of discrimination: (1) internalized trans-hostility and "protection" of cis individuals, (2) lack of knowledge/uncertainties regarding transition, (3) "protection" of a binary worldview, (4) binary worldview in medicine, (5) structural deficits, (6) asymmetric interactions with specialists, (7) current political debate, (8) view of transgender individuals as a "burden for society", (9) objectification, (10) homophobia, (11) misogyny/androcentrism and (12) discrimination as reaction to discrimination.

CONCLUSIONS

German transgender individuals have a very differentiated picture regarding their subjective reasons for experiencing discrimination in healthcare. Overall, disrespect regarding gender identity and a confrontation with foreignness seems to be seen as the decisive factor. Thus, it is not enough to focus only on measures that aim to remedy the information deficit on the part of medical providers. Measures must be taken that can create a granting and respectful attitude towards transgender individuals.

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.

Taking up the challenge of trans and non-binary inclusion in midwifery education: Reflections from educators in Aotearoa and Ontario Canada

Perinatal services are being challenged to acknowledge that not all pregnant and birthing people are women and to ensure the design and delivery of services that are inclusive of, and deliver equitable outcomes for, trans, non-binary, and other gender diverse people. This is posing unique challenges for midwifery with its women-centred philosophy and professional frameworks. This paper presents the critical reflections of midwifery educators located in two midwifery programmes in Aotearoa¹ and Ontario Canada, who are engaged in taking up the challenge of trans and non-binary inclusion in their local contexts. The need to progress trans and non-binary inclusion in midwifery education to secure the human rights of gender diverse people to safe midwifery care and equitable perinatal outcomes is affirmed. We respond to an existing lack of research or guidance on how to progress trans and non-binary inclusion in midwifery education. We offer our insights and reflections organised as four themes located within the frameworks of cultural humility and safety. These themes address midwifery leadership for inclusion, inclusive language, a broader holistic approach, and the importance of positioning this work intersectionally. We conclude by affirming the critical role of midwifery education/educators in taking up the challenge of trans and non-binary inclusion to ensure a future midwifery workforce skilled and supported in the provision of care to the growing gender diverse population.

The Complexity of Trauma for LGBTQ+ People

Trauma care is complex. Acute and critical care clinicians perceive trauma as a skilled response to critical injury or accident that occurs to patients, but trauma exists on many levels. One of those is a grim reality for patients who are lesbian, gay, bisexual, transgender, queer or questioning, and from other sexual and gender minorities (LGBTQ+). A lifetime of trauma through stigma, discrimination, and victimization is too often present. Owing to distrust of the health care system and clinicians, LGBTQ+ experience health and health care disparities.

Optimal training in communication model (OPTiCOM): A programmatic roadmap

OBJECTIVES

Teaching primary care residents patient communication skills is essential, complex, and impeded by barriers. We find no models guiding faculty how to train residents in the workplace that integrate necessary system components, the science of physician-patient communication training and competency-based medical education. The aim of this project is to create such a model.

METHODS

We created OPTiCOM using four steps: (1) communication educator interviews, analysis and theme development; (2) initial model construction; (3) model refinement using expert feedback; (4) structured literature review to validate, refine and finalize the model.

RESULTS

Our model contains ten interdependent building blocks organized into four developmental tiers. The Foundational value tier has one building block Naming relationship as a core value. The Expertize and resources tier includes four building blocks addressing: Curricular expertize, Curricular content, Leadership, and Time. The four building blocks in the Application and development tier are Observation form, Faculty development, Technology, and Formative assessment. The Language and culture tier identifies the final building block, Culture promoting continuous improvement in teaching communication.

CONCLUSIONS

OPTiCOM organizes ten interdependent systems building blocks to maximize and sustain resident learning of communication skills. Practice Implications Residency faculty can use OPTiCOM for self-assessment, program creation and revision.

The Inclusion of LGBTQ+ Health across the Lifespan in Pre-Registration Nursing Programmes: Qualitative Findings from a Mixed-Methods Study

Poor physical and mental ill-health is experienced by many LGBTQ+ people, compounded by a reluctance to access healthcare services. This reluctance is attributed to experiences of heteronormative assumptions and negative attitudes encountered. Despite increasing recognition of the need to include LGBTQ+ health in undergraduate healthcare programmes, inconsistencies and gaps in content, skills development, and assessment are still apparent. The aim of the study was to identify LGBTQ+ health content within nursing and midwifery pre-registration programmes and identify education best practice and innovation. A mixed-methods study involving a quantitative and qualitative design was undertaken. The qualitative findings from a nursing perspective were extracted from the dataset for further detailed analysis and are reported in this paper. Information about the study and an online survey were distributed to 135 Schools of Nursing and Midwifery in the UK and Ireland. Individual semi-structured online interviews took place with academics. Qualitative data from 29 survey responses and 12 follow-up interviews were thematically analysed. Eight of the 12 follow-up interviews were held with nursing academics and following data analysis three themes emerged: (i) LGBTQ+ health across the lifespan; (ii) taking the initiative for LGBTQ+ health inclusion; and (iii) identifying and overcoming challenges. The findings highlight the endeavours by nursing academics to integrate LGBTQ+ health within pre-registration programmes to meet the education needs of students and the opportunity to develop curriculum content to address the needs and concerns of LGBTQ+ people across the lifespan.

Gender Diverse Representation in Patient Simulation: A Scoping Review

PURPOSE

Despite recent advocacy for transgender and nonbinary (TGNB) health competencies in medical education, there is little guidance on how to represent diverse gender identities for clinical skills training. Published literature is one of few resources available to inform educators' decisions, so this study aims to summarize how medical education scholarship portrays TGNB identities in patient simulation.

METHOD

This scoping review used PRISMA guidelines with search strings encompassing diverse gender identities and patient simulation. This search was completed in July 2021, and all years of publication were included. The authors completed a 3-tiered review to identify relevant studies and then extracted data to summarize how TGNB patients were portrayed and training outcomes.

RESULTS

After screening 194 total articles, 44 studies met the criteria for full review. Of these, 22 studies involved TGNB simulated patient cases. Within these, 15 (68%) reported the specific gender identities represented in the patient case, revealing mostly binary transgender identities. Sixteen studies (73%) reported the gender identities of all actors who portrayed the patient. The identities of all patients and actors matched in only 10 articles (45%), indicating that most programs portray TGNB identities with cisgender or unspecified standardized patients. Nearly all studies reported desirable learner outcomes. Several noted the advantage of authenticity in recruiting TGNB actors and the need to achieve more accurate representation of TGNB patients.

CONCLUSIONS

Educators are increasingly representing TGNB identities in clinical skills training. These results show a lack of nonbinary representation and discrepancies between TGNB patient cases and standardized patient identities. These data also suggest that simulation programs need and desire better recruitment strategies within TGNB communities. Because TGNB communities are not a monolith, reporting out and analyzing gender identities of simulation cases and people hired to portray TGNB patients helps ensure that TGNB care is taught effectively and respectfully.

Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents

Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.

Assessing Use of Gender Diverse Language in Patient Education Materials on Breast Reconstruction

Utilizing inclusive terminology in patient education materials is an increasing area of focus in plastic surgery. Over 300,000 cases of breast cancer were diagnosed in 2020, affecting cisgender and gender diverse patients alike. Both cisgender and gender diverse patients may choose to undergo breast reconstruction. This study aims to assess the use of inclusive language in online patient education materials on reconstruction after breast cancer.

Shifting language for shifting anatomy: Using inclusive anatomical language to support transgender and nonbinary identities

While navigating a medical or surgical gender transition, transgender, and nonbinary people encounter anatomical language and concepts through their own informal research on the topics and directly through healthcare providers. Use of appropriate and inclusive language is important for affirming identities and can be fostered at any point during professional training through modeling of inclusive language and in the formal curriculum, including during anatomical education. In this article we discuss anatomical language and how it intersects with gender identity, first from the perspective of a transgender patient, then from the perspective of an anatomy educator. The patient shared how she benefited from informative resources, nongendered language, language tailored to her level of understanding, and providers not making generalizations about her based on her anatomy or sex assigned at birth. The educator shared her experience developing a primer on sex and gender that moved beyond a prescriptive binary and exposed students to language and concepts inclusive of diverse sexual and gender identities. Recommendations were made related to how to implement these lessons and better explore how transgender and nonbinary individuals experience anatomical language and the potential impact of language that is inclusive of gender-diverse persons in anatomical education as part of health professions programs. While sound medicine, procedure, science, and experienced professional skill were necessary, an essential positive aspect of the medical and gender transitions discussed was an intentionality around language by providers-including anatomical language.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Health care access among transgender and nonbinary people in Canada, 2019: a cross-sectional survey

BACKGROUND

Previous Canadian studies have identified problems regarding health care access for transgender (trans) and nonbinary people, but all-ages national data have been lacking. This study describes access to care among trans and nonbinary people in Canada, and compares health care access across provinces or regions.

METHODS

We conducted a bilingual, multimode cross-sectional survey (Trans PULSE Canada) from July 26 to Oct. 1, 2019. We recruited trans and nonbinary people aged 14 years and older using convenience sampling. We assessed 5 outcomes: having a primary care provider, having a primary care provider with whom the respondent was comfortable discussing trans health issues, past-year unmet health care need, medical gender affirmation status, and being on a wait-list to access gender-affirming medical care. Average marginal predictions were estimated from multivariable logistic regression models with multiply imputed data.

RESULTS

The survey included 2873 participants, and 2217 surveys were analyzed after exclusions. Of the 2217 trans and nonbinary respondents, most had a primary care provider (n = 1803; 81.4%, 95% confidence interval [CI] 79.8%-83.0%), with model-predicted probabilities from 52.1% (95% CI 20.2%-84.1%) in the territories to 92.9% (95% CI 83.5%-100.0%) in Newfoundland and Labrador. Of the respondents, 52.3% (n = 1150; 95% CI 50.3%-54.2%) had a primary care provider with whom they were comfortable discussing trans health issues, and 44.4% (n = 978; 95% CI 42.3%-46.4%) reported an unmet health care need. Among participants who needed gender-affirming medical treatment (n = 1627), self-defined treatment completion ranged from an estimated 16.8% (95% CI 0.6%-32.5%) in Newfoundland and Labrador to 59.1% (95% CI 52.5%-65.6%) in Quebec. Of those who needed but had not completed gender-affirming care at the time of the study (n = 1046), 40.7% (n = 416; 95% CI 37.8%-43.6%) were on a wait-list, most often for surgery. These outcomes, with the exception of having a provider with whom one is comfortable discussing trans issues, varied significantly by province or region (p < 0.05).

INTERPRETATION

Participants reported considerable unmet needs or delays in primary, general and gender-affirming care, with significant regional variation. Our results indicate that, despite efforts toward equity in access to care for trans and nonbinary people in Canada, inequities persist.

Medical Care for Nonbinary Youth: Individualized Gender Care Beyond a Binary Framework

Nonbinary and genderqueer youth represent well over a one-third of transgender youth. Historically, transgender health care has been based on the gender binary, and as a result, many nonbinary people have chosen to forego care or withhold their authentic needs or goals when accessing care. This article presents a paradigm shift in gender care, which addresses discrimination and stigma and outlines components of supportive and affirming care to gender expansive youth. Nonbinary youth are best served when providers use gender-affirming language and focus on embodiment goals. Medical interventions may include pubertal suppression, hormones, and surgeries, which are best reviewed by individual physical effects rather than with "masculinizing" or "feminizing" terminology. Individualized goals may be supported by estrogen, testosterone, or a combination of both. Providers should be prepared to facilitate supportive conversations, difficult decisions, and balancing of priorities with nonbinary patients and their families. [Pediatr Ann. 2021;50(9):e384-e390.].

Ethical issues in participatory arts methods for young people with adverse childhood experiences

Context

Participatory arts‐based methods such as photovoice, drama and music have increasingly been used to engage young people who are exposed to psychosocial risks. These methods have the potential to empower youth and provide them with an accessible and welcoming environment to express and manage difficult feelings and experiences. These effects are, however, dependent on the way these methods are implemented and how potential ethical concerns are handled.

Objective

Using the current literature on arts‐based health research as a foundation, this paper examines ethical issues emerging from participatory arts methods with young people with traumatic experiences.

Results

We present a typology covering relevant issues such as power, accessibility, communication, trust and ownership, across the domains of partnership working, project entry, participation and dissemination. Drawing on our extensive clinical and research experiences, existing research and novel in‐practice examples, we offer guidance for ethical dilemmas that might arise at different phases of research.

Conclusion

Adequate anticipation and consideration of ethical issues, together with the involvement of young people, will help ensure that arts methods are implemented in research and practice with young people in a fair, meaningful and empowering way.

Patient or Public Contribution

The issues reviewed are largely based on the authors' experience conducting participatory research. Each of the projects referenced has its own systems for PPI including, variously, consultations with advisory groups, coproduction, youth ambassadors and mentor schemes. One of the coauthors, Josita Kavitha Thirumalai, is a young person trained in peer support and has provided extensive input across all stages.

Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent

INTRODUCTION

Diverse sex development (dsd) is an umbrella term for different congenital conditions with incongruence of chromosomal, gonadal, and phenotypic sex characteristics. These are accompanied by various uncertainties concerning health-related, medical, psychosocial, and legal issues that raise controversial discussion.

AIM

The aim of this exploratory study was to investigate 3 questions: What are the most controversial and disputed issues in the context of intersex/dsd? Which issues are associated with the biggest knowledge gaps? Which issues involve the greatest difficulty or uncertainty in decision-making? A further aim was to investigate whether the group of persons concerned, the parents of intersex children, and the group of experts in the field had differing views regarding these questions.

METHODS

A self-developed questionnaire was distributed among persons concerned, parents of children with intersex/dsd, and experts in the field. It contained open and multiple-choice questions. The answers from 29 participants were entered into data analysis. A mixed-method approach was applied. Quantitative data were analysed descriptively. Qualitative data were analysed according to the principles of qualitative content analysis.

MAIN OUTCOME MEASURE

Participants answered questions on the most controversial and disputed issues, issues associated with the biggest knowledge gaps, and issues associated with the most difficulty or uncertainty in decision-making.

RESULTS

The findings indicate that controversial issues and uncertainties mainly revolve around surgical interventions but also around the question of how to adequately consider the consent of minors and how to deal with intersex in the family. Significant differences were found between persons concerned and parents vs academic experts in the field regarding the perceptions of procedure of diagnostic investigation and/or treatment in adulthood, on legal questions concerning marriage/registered civil partnerships, and on lack of psychosocial counseling close to place of residence.

CONCLUSION

The necessity of irreversible gonadal and genital surgery in early childhood is still a matter of strong controversy. To ensure the improvement in well-being of intersex persons, including a sexual health perspective, the positive acceptance of bodily variance is an important prerequisite. Psychosocial support regarding one-time decisions as well as ongoing and changing issues of everyday life appears to be an important means in reaching overall quality of life. Lampalzer U, Briken P, Schweizer K. Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent-A Pilot Study. Sex Med 2020;8:472-489.

Intersecting Experiences of Healthcare Denials Among Transgender and Nonbinary Patients

INTRODUCTION

Transgender and nonbinary individuals experience high levels of health disparities and are more likely to experience denials of health care than their cisgender (nontransgender) counterparts. There is a lack of evidence on how healthcare denials vary by gender identity and other intersecting identity characteristics in the transgender and nonbinary populations.

METHODS

Using data from the 2015 U.S. Trans Survey (n=27,715), multivariate logistic regressions were used to analyze (in 2019) the increased likelihood of experiencing denials of trans-related care and standard care across socioeconomic and identity characteristics among the transgender and nonbinary population, including race, age, educational attainment, disability, income, and gender identity.

RESULTS

Almost 8% of the participants had been denied trans-specific health care, and >3% had been refused general health care. Transgender (compared with nonbinary), older, biracial, or multiracial, and lower-income participants, as well as those with less than a high school diploma and those with disabilities, were significantly more likely to experience refusal of care in general or trans-specific healthcare settings.

CONCLUSIONS

There is a need for better training of healthcare providers to be inclusive and reduce denial rates of their transgender and nonbinary patients. However, it is also clear that current rates of denial must be considered through a whole-person lens, considering the experience of concurrent oppressed identities and recognizing the increased risk those with multiple marginalized identities experience in being denied needed health care.

A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients

BACKGROUND

Increasingly more nonbinary patients are obtaining better access for gender-affirming chest surgery (top surgery), representing an important subset of patients who undergo such surgery.

OBJECTIVE

We review our experience at gender-affirming chest surgery in nonbinary versus transmasculine patients in an integrated health care setting.

METHODS

We performed a retrospective study of nonbinary and transmasculine patients who underwent gender-affirming chest surgery from May 1, 2012, to December 27, 2017.

RESULTS

There were 111 nonbinary patients and 665 transmasculine patients included in the final analyses. Nonbinary patients were more likely to seek more than 1 surgical consultations than transmasculine patients (24.3% vs 1.7%, respectively, P < 0.0001). More nonbinary patients (17.3%) indicated nipple sensation to be important relative to their transmasculine counterparts (0.4%, P < 0.0001). Fewer nonbinary patients were on testosterone before surgery (33.64%) in comparison to transmasculine patients (86.14%, P < 0.0001). When only prior reduction mammaplasty or top surgery were considered, nonbinary patients (8.1%) were more likely than transmasculine patients (3.5%) to have had a prior chest surgery. When evaluating patients who did not have prior chest surgery before undergoing top surgery at our institution (n = 721), rates of major complications, minor complications, as well as revisions, were comparable between nonbinary and transmasculine patients.

CONCLUSIONS

This study demonstrated that more nonbinary patients requested nonflat chests relative to their transmasculine counterparts. Both groups in our sample displayed comparable rates of complications after top surgery.

A Blueprint for Planning and Implementing a Transgender Health Program

Transgender and gender-diverse people face multiple barriers to accessing appropriate health care, including denial of service, harassment, and lack of clinician knowledge. This article presents a blueprint for planning and implementing a transgender health program within a primary care practice in order to enhance the capacity of the health care system to meet the medical and mental health needs of this underserved population. The steps described, with emphasis on elements specific to transgender care, include conducting a community needs assessment, gaining commitment from leadership and staff, choosing a service model and treatment protocols, defining staff roles, and creating a welcoming environment.

Comparing the health of non-binary and binary transgender adults in a statewide non-probability sample

BACKGROUND

In the U.S., non-binary refers to transgender people who have a gender identity not aligned with their assigned sex at birth, and who identify outside of the traditional male-female binary, such as genderqueer, genderfluid, or gender nonconforming. Few data are available to characterize the health of non-binary adults.

METHODS

The current study sought to fill this gap by conducting a secondary analysis of data from a non-probability sample of transgender and/or gender nonconforming adults in Massachusetts (sample mean age 32.6 years, 63% female assigned sex at birth; 79.4% white non-Hispanic/Latinx). Multivariable models were fit to compare non-binary (e.g., genderqueer) vs. binary (e.g., man/trans man, woman/trans woman) respondents across a range of social and health indicators.

RESULTS

Overall, 40.9% identified their gender identity as non-binary. Non-binary respondents significantly differed from binary respondents on (all p<0.05): demographics (younger age, more female assigned sex at birth); gender affirmation (older age of identity recognition, lower current uptake of and future desires for medical gender affirmation); healthcare utilization (lower rates of being up-to-date in annual wellness visit, less mental healthcare utilization in past year); mental health and substance use (higher past-week depressive distress, higher hazardous alcohol use); social history (more unstably housed, more current students), violence victimization (lower rates of lifetime intimate partner violence), and social support (less family support).

CONCLUSION

Gender diversity, including whether people endorse a binary or non-binary gender identity, is a prevalent and an important aspect of transgender health. Demographic measures of gender identity that include binary and non-binary response options are recommended to inform future research and clinical care.