Access to healthcare among transgender and non-binary youth in Sweden and Spain: A qualitative analysis and comparison

BACKGROUND

Transgender and non-binary (TGNB) people tend to report worse health than cis people, however, despite an increased need for care, they face several barriers when trying to access healthcare. These barriers might be exacerbated when young age intersects with a trans identity, and so there is a need for studies highlighting the experiences of TGNB youth.

AIMS

To explore and compare how TGNB youth (15-26 years old) in Sweden and Spain experienced their access to healthcare, in order to shed light on the strengths and limitations of different kinds of healthcare systems and improve healthcare provision and policy development.

METHODS

This study was based on a qualitative analysis of semi-structured interviews with TGNB youth living in Sweden (n = 16) and Spain (n = 18). Of these, 22 identified as male or transmasculine, six as non-binary, and six as women or transfeminine; 25 had undergone some type of gender-affirming care, and the rest were on the waiting list or undergoing preparatory visits and had not started hormonal treatment. The interviews were analyzed using reflexive thematic analysis. An abductive approach was applied, and the Levesque conceptual framework was used to compare the analyses of each set of materials.

RESULTS

We present our findings using the structure of the accessibility framework, focusing on approachability, acceptability, availability, affordability, and appropriateness. The conceptualization of accessibility in combination with the concept of cisnormativity illustrates how specific ideals and normative expectations affect access to healthcare for TGNB people across contexts, with most barriers arising from the appropriateness of the services.

DISCUSSION

Young TGNB people experience barriers to accessing healthcare both in the Spanish and the Swedish contexts. Strategies to reduce these barriers should be framed within the critique of and resistance to cisnormativity and should focus on users with intersecting marginalized identities to promote health equity.

"Discrimination is harder to live with than the disease": an interview study of the perceptions and experiences of sexual and reproductive health and rights among women living with HIV in Sweden

Around 40% of people living with human immunodeficiency virus (HIV) in Sweden are women. However, little is known about their experiences, particularly those related to sexual and reproductive health and rights (SRHR). This study aims to explore perceptions and experiences of SRHR among women living with HIV (LWH). Twelve interviews were conducted with women LWH from September to October 2019 and analysed using thematic analysis. The central theme describing participants' experiences of social relationships, intimate encounters and reproductive life, "Discrimination is harder to live with than the disease itself", is based on three themes that contain subthemes. Theme 1 describes how participants reconsider and reorient their sexual and reproductive life after diagnosis. Theme 2 highlights how (mis)perceptions of HIV affect sexual and reproductive life and lead to abusive treatment and internalisation. Theme 3 describes a paradoxical shift of responsibilities where participants experience being compelled to take greater responsibility in some situations and stripped of the right to decide in others. This study suggests that despite notable progress in HIV treatment, stigma and discrimination stemming from outdated beliefs and (mis)conceptions, ambiguous policies and guidelines, and unequal access to information affect SRHR experiences of women LWH more than the virus itself. The results emphasise the need to: update knowledge within healthcare settings and among the public; clarify ambiguous legislations and guidelines; ensure equal access to information to enable all women LWH to take informed decisions, make fully informed choices and realise their SRHR; and consider the diversity of women LWH and enable shared decision-making.

Exploring Motives and Perceived Barriers for Voice Modification: The Views of Transgender and Gender-Diverse Voice Clients

PURPOSE

To date, transgender and gender-diverse voice clients' perceptions and individual goals have been missing in discussions and research on gender-affirming voice therapy. Little is, therefore, known about the client's expectations of therapy outcomes and how these are met by treatments developed from views of vocal gender as perceived by cisgender persons. This study aimed to explore clients' individual motives and perceived barriers to undertaking gender-affirming voice therapy.

METHOD

Individual, semistructured interviews with 15 transgender and gender-diverse voice clients considering voice therapy were conducted and explored using qualitative content analysis.

RESULTS

Three themes were identified during the analysis of the participants' narratives. In the first theme, "the incongruent voice setting the rules," the contribution of the voice on the experienced gender dysphoria is put in focus. The second theme, "to reach a voice of my own choice," centers around anticipated personal gains using a modified voice. The third theme, "a voice out of reach," relates to worries and restricting factors for not being able to reach one's set goals for voice modification.

CONCLUSIONS

The interviews clearly indicate a need for a person-centered voice therapy that starts from the individuals' expressed motives for modifying the voice yet also are affirmative of anticipated difficulties related to voice modification. We recommend that these themes should form the basis of the pretherapy joint discussion between the voice client and the speech-language pathologist to ensure therapy goals that are realistic and relevant to the client.

Protecting, managing and bending boundaries: a biomedicalization perspective on Swedish youth clinics’ responses to mental (ill) health

Background

Sweden has provided around 300 youth clinics (YCs) to address the health needs of young people since the 1970s. During the last few years, and as part of an effort to strengthen mental healthcare for young people, YCs’ role in the provision of mental healthcare has been widely debated. With such debates as background, the aim of this study is to analyse Swedish YCs’ responses to the mental (ill) healthcare needs of young people, from the perspective of national level stakeholders.

Methods

We used thematic analysis of interviews with eight national level stakeholders in the field of youth mental health in Sweden. Building upon the concept of biomedicalization we examined the discourses on mental (ill) health, healthcare and youth that such responses reproduce.

Results

YCs engage in the three simultaneous, but at times contradictory, responses of protecting, managing and bending boundaries. Remaining true to their mission as a health-promotion service compels them to protect their boundaries and limit the type of mental health issues they address. However, the perceived malfunctioning of specialized services has led them to bend these boundaries to allow in more young people with severe mental health problems. Caught between protecting and bending boundaries, the response of managing boundaries to decide who should be allowed in and who should be sent elsewhere has emerged as a middle-way response. However, it is not free from conflicts.

Conclusion

Building upon the concept of biomedicalization, this study poses two questions. The first relates to whether it is possible to support young people and their health without reinforcing discourses that represent young people as collectively at risk, and if so how this can be done. The second relates to the provision of mental healthcare for young people, and the need to identify conditions for integrating diagnosis and treatment within YCs, without hindering their holistic and youth-centred approach.

"A one-size-fits-all model is not good"?: ambivalent perceptions and experiences of African immigrant parents towards Swedish sexual and reproductive health services for young people

Objective

Parents have a key role regarding young people’s access to sexual and reproductive health services, thus their perceptions go a long way towards promoting or discouraging young people from using such services. Research has revealed that immigrant young people in Sweden access these essential services to a lesser extent than their native peers, and that they perceive their parents as unsupportive of such visits. This pilot study’s objective was to explore immigrant parents’ perceptions and experiences of the sexual and reproductive health services provided by Swedish youth clinics.

Results

Two categories were developed from the data analysis: (i) Youth clinics are well-known (to some) and appreciated (to a certain extent), and (ii) Parents feel left out from youth clinics and that the clinics have taken over parental responsibility. This study presents an ambivalent scenario connected to immigrant parents’ experiences and perceptions of having neither a space nor a voice within the existing youth clinic model. Parents expressed the desire for the youth clinics to recognise their cultural backgrounds, norms, and beliefs while providing sexual and reproductive health services to their children.

(Un)safe spaces, affective labour and perceived health among people with trans experiences living in Sweden

Lack of safe space has been connected to ill health among people with trans experiences. This study analyses trans people's experiences of being in public, semi-public and community spaces using the analytical concept of safety/unsafety in relation to perceived health. The analytic framework draws on the concepts of cisgenderism, orientation, lines and comfort. The material analysed consisted of 18 individual interviews with people with trans experiences, which were analysed using constructivist thematic analysis. The analysis resulted in the identification of three themes: straightening devices creating limited living space, orienting oneself in (cis)gendered spaces and creating safer (?) community spaces for healing. Experiences of unsafety ranged from incidents and fear of different kinds of violence in public and semi-public spaces to the lack of a transpolitically informed agenda in, for example, feminist spaces. Safer spaces helped participants to feel a sense of belonging, to share their experiences and to heal. Experiences of unsafety and discomfort are important as they will help us to understand the health situations of people with trans experiences. It is important to facilitate the creation of safer spaces to improve the health of members of this group.

Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain

Background

Immigrant populations face diverse barriers to accessing appropriate healthcare services on several levels. In the Basque Country, Sub-Saharan African women were identified as facing the largest barriers to access them. The aim of the study is to analyse Sub-Saharan African immigrant women's perceptions and experiences of access to appropriate healthcare in the public health system in the Basque Country, Spain.

Methods

Fourteen women from eight Sub-Saharan African countries who have used the Basque public healthcare services were interviewed. A qualitative content analysis was applied: meaning that units were identified, coded and the resulting codes were then organized into three categories.

Results

The first category, Fearing to enter a health system perceived as not friendly for immigrants, included factors, mainly those related to legal conditions for accessing healthcare services and lack of lawful documentation, that made women avoid or discontinue seeking out healthcare.

The second category, Being attended on professionals' own communication terms, comprised how the lack of effective communication compromised not only the access of the immigrant women to healthcare services, but also their health.

Lastly, the third category, Is mistreatment based on racism or merely on bad luck? described how being an immigrant and black influenced the way they were (mis)treated in the health system.

Conclusion

For Sub-Saharan African immigrant women, accessing appropriate healthcare in the Basque Country was perceived to be subject to institutional barriers. At the legal level, barriers included lack of entitlement, difficulties in fulfilling legal access conditions and lack of documentation. The lack of communication with health centre staff and their attitudes, guided by a stereotyped social image of immigrants and black people, also hindered their possibilities of receiving appropriate healthcare. Facilitators for accessing healthcare included strategies from individual professionals, personal networks and social actors to help them to cope with the barriers. There is a need of reinforcing inclusion values and rights-based approach to attention among staff at the health centres to have more non-discriminatory and culturally appropriate health systems.

“It was like I had to fit into a category”: Care-seekers’ experiences of gender regulation in the Swedish trans-specific healthcare

The few previous studies investigating regulation of gender in trans-specific healthcare are mainly based on text material and interviews with care-providers or consist solely of theoretical analyses. There is a lack of studies analysing how the regulation of gender is expressed in the care-seeker’s own experiences, especially in a Nordic context. The aim of this study is to analyse narratives of individuals with trans experiences (sometimes called transgender people) to examine how gender performances can be regulated in trans-specific care in Sweden. The conceptual framework is inspired by trans studies, a Foucauldian analysis of power, queer phenomenology and the concept of cisnormativity. Fourteen interviews with people with trans experiences are analysed with constructivist grounded theory. The participants’ experiences indicate that gender is constructed as norm-conforming, binary and stable in trans-specific healthcare. This gendered position is resisted, negotiated and embraced by the care-seekers. Norms and discourses both inside and outside trans-specific care contribute to the regulation and limit the room for action for care-users. We conclude that a trans-specific care that has a confirming approach to its care-users, instead of the current focus on gender norm conformity, has the potential to increase the self-determination of gender performance and increase the quality of care.

Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in Northern Sweden

Background

Studies from Sweden and abroad have established health inequalities between heterosexual and non-heterosexual people. Few studies have examined the underpinnings of such sexual orientation inequalities in health. To expand this literature, the present study aimed to employ decomposition analysis to explain health inequalities between people with heterosexual and non-heterosexual orientation in Sweden, a country with an international reputation for heeding the human rights of non-heterosexual people.

Methods

Participants (N = 23,446) came from a population-based cross-sectional survey in the four northernmost counties in Sweden in 2014. Participants completed self-administered questionnaires, covering sexual orientation, mental and general physical health, social conditions and unmet health care needs, and sociodemographic data was retrieved from total population registers. Sexual orientation inequalities in health were decomposed by Blinder-Oaxaca decomposition analysis.

Results

Results showed noticeable mental and general health inequalities between heterosexual and non-heterosexual orientation groups. Health inequalities were partly explained (total explained fraction 64-74%) by inequalities in degrading treatment (24-26% of the explained fraction), but to a considerable degree also by material conditions (38-45%) and unmet care needs (25-43%).

Conclusions

Psychosocial experiences may be insufficient to explain and understand health inequalities by sexual orientation in a reputedly ‘gay-friendly’ setting. Less overt forms of structural discrimination may need to be considered to capture the pervasive material discrimination that seems to underpin the embodiment of sexual minority inequalities. This ought to be taken into consideration in research, policy-making and monitoring aiming to work towards equity in health across sexual orientations.