Exploring the gender care experiences and perspectives of individuals who discontinued their transition or detransitioned in Canada

BACKGROUND

Those who detransition have received increased public and scholarly attention and their narratives are often presented as evidence of limitations with contemporary gender-affirming care practices. However, there are scant empirical studies about how this population experienced their own process of gaining access to gender-affirming medical/surgical interventions, or their recommendations for care practice.

AIMS

To qualitatively explore the care experiences and perspectives of individuals who discontinued or reversed their gender transitions (referred to as detransition).

METHODS

Between October 2021-January 2022, Canadian residents aged 18 and older with experience of stopping, shifting, or reversing a gender transition were invited to participate in semi-structured, one-on-one, virtual interviews. A purposive sample of 28 was recruited by circulating study adverts over social media, to clinicians in six urban centres, and within participants' social networks. Interviews ranged between 50-90 minutes, were audio-recorded, and transcribed verbatim. Following constructivist grounded theory methodology, interview data were analyzed inductively and thematically following a two-phase coding process to interpret participants' experiences of, and recommendations for, gender care.

RESULTS

Participants were between the ages of 20-53 (71% were between 20-29). All participants identified along the LGBTQ2S+ spectrum. Twenty-seven out of 28 of the participants received medical/surgical interventions (60% were ages 24 and younger). A majority (57%) reported three or more past gender identities, with 60% shifting from a binary transgender identity at the time of initiating transition to a nonbinary identity later in their transition journey. To access medical/surgical interventions, most participants were assessed via the gender-affirming care model pathway and also engaged in talk therapy with a mental healthcare provider such as a psychologist or psychiatrist. Some participants experienced their care as lacking the opportunity to clarify their individual treatment needs prior to undergoing medical/surgical transition. Decisional regret emerged as a theme alongside dissatisfaction with providers' "informed consent" procedures, such that participants felt they would have benefitted from a more robust discussion of risks/benefits of interventions prior to treatment decision-making. Overall, participants recommended an individualized approach to care that is inclusive of mental healthcare supports.

CONCLUSIONS

To optimize the experiences of people seeking and receiving gender care, a thorough informed consent process inclusive of individualized care options is recommended, as outlined by the World Professional Association of Transgender Health, standards of care, version 8.

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

Disruptions of sexually transmitted and blood borne infections testing services during the COVID-19 pandemic: accounts of service providers in Ontario, Canada

BACKGROUND

Since the onset of the COVID-19 pandemic in March 2020 in Canada, the availability of sexual health services including sexually transmitted and blood-borne infection (STBBI) testing has been negatively impacted in the province of Ontario due to their designation as "non-essential" health services. As a result, many individuals wanting to access sexual healthcare continued to have unmet sexual health needs throughout the pandemic. In response to this, sexual health service providers have adopted alternative models of testing, such as virtual interventions and self-sampling/testing. Our objective was to investigate service providers' experiences of disruptions to STBBI testing during the COVID-19 pandemic in Ontario, Canada, and their acceptability of alternative testing services.

METHODS

Between October 2020-February 2021, we conducted semi-structured virtual focus groups (3) and in-depth interviews (11) with a diverse group of sexual health service providers (n = 18) including frontline workers, public health workers, sexual health nurses, physicians, and sexual health educators across Ontario. As part of a larger community-based research study, data collection and analysis were led by three Peer Researchers and a Community Advisory Board was consulted throughout the research process. Transcripts were transcribed verbatim and analysed with NVivo software following grounded theory.

RESULTS

Service providers identified the reallocation of public health resources and staff toward COVID-19 management, and closures, reduced hours, and lower in-person capacities at sexual health clinics as the causes for a sharp decline in access to sexual health testing services. Virtual and self-sampling interventions for STBBI testing were adopted to increase service capacity while reducing risks of COVID-19 transmission. Participants suggested that alternative models of testing were more convenient, accessible, safe, comfortable, cost-effective, and less onerous compared to traditional clinic-based models, and that they helped fill the gaps in testing caused by the pandemic.

CONCLUSIONS

Acceptability of virtual and self-sampling interventions for STBBI testing was high among service providers, and their lived experiences of implementing such services demonstrated their feasibility in the context of Ontario. There is a need to approach sexual health services as an essential part of healthcare and to sustain sexual health services that meet the needs of diverse individuals.

Academic Productivity of Equity-Deserving Physician Scholars During COVID-19: A Scoping Review

PURPOSE

The COVID-19 pandemic presented new barriers and exacerbated existing inequities for physician scholars. While COVID-19's impact on academic productivity among women has received attention, the pandemic may have posed additional challenges for scholars from a wider range of equity-deserving groups, including those who hold multiple equity-deserving identities. To examine this concern, the authors conducted a scoping review of the literature through an intersectionality lens.

METHOD

The authors searched peer-reviewed literature published March 1, 2020, to December 16, 2021, in Ovid MEDLINE, Ovid Embase, and PubMed. The authors excluded studies not written in English and/or outside of academic medicine. From included studies, they extracted data regarding descriptions of how COVID-19 impacted academic productivity of equity-deserving physician scholars, analyses on the pandemic's reported impact on productivity of physician scholars from equity-deserving groups, and strategies provided to reduce the impact of the COVID-19 pandemic on academic productivity of physician scholars from equity-deserving groups.

RESULTS

Of 11,587 unique articles, 44 met inclusion criteria, including 15 nonempirical studies and 29 empirical studies (22 bibliometrics studies, 6 surveys, and 1 qualitative study). All included articles focused on the gendered impact of the pandemic on academic productivity. The majority of their recommendations focused on how to alleviate the burden of the pandemic on women, particularly those in the early stages of their career and/or with children, without consideration of scholars who hold multiple and intersecting identities from a wider range of equity-deserving groups.

CONCLUSIONS

Findings indicate a lack of published literature on the pandemic's impact on physician scholars from equity-deserving groups, including a lack of consideration of physician scholars who experience multiple forms of discrimination. Well-intentioned measures by academic institutions to reduce the impact on scholars may inadvertently risk reproducing and sustaining inequities that equity-deserving scholars faced during the pandemic.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

"Mental Readiness" and Gatekeeping in Trans Healthcare

Gatekeeping refers to clinicians' strict application of eligibility criteria to determine a trans patient's "fitness" to engage in medical transition, resulting in significant barriers to gender-affirming care. Gatekeeping often uses "mental readiness" as a prerequisite to medical transition, which contributes to patient distress and systemic discrimination. Changing international trans health guidelines (the new World Professional Association for Transgender Health Standards of Care version 8) recommends clinicians shift from a gatekeeping model towards an informed consent model, which improves access to care. This commentary offers recommendations on how clinicians can reconsider existing "mental readiness" frameworks around medical transition to facilitate improved access to care.

Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments

IMPORTANCE

Medical education, research, and clinical guidelines are available to support the initiation of gender-affirming care for transgender and nonbinary people. By contrast, little is known about the clinical experiences of those who discontinue or seek to reverse gender-affirming medical or surgical interventions due to a change in gender identity, often referred to as detransition.

OBJECTIVE

To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants' social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed.

MAIN OUTCOMES AND MEASURES

In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions.

RESULTS

Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.

CONCLUSIONS AND RELEVANCE

This study's results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.

Preventing transition "regret": An institutional ethnography of gender-affirming medical care assessment practices in Canada

When a person openly "regrets" their gender transition or "detransitions" this bolsters within the medical community an impression that transgender and non-binary (trans) people require close scrutiny when seeking hormonal and surgical interventions. Despite the low prevalence of "regretful" patient experiences, and scant empirical research on "detransition", these rare transition outcomes profoundly organize the gender-affirming medical care enterprise. Informed by the tenets of institutional ethnography, we examined routine gender-affirming care clinical assessment practices in Canada. Between 2017 and 2018, we interviewed 11 clinicians, 2 administrators, and 9 trans patients (total n = 22), and reviewed 14 healthcare documents pertinent to gender-affirming care in Canada. Through our analysis, we uncovered pervasive regret prevention techniques, including requirements that trans patients undergo extensive psychosocial evaluations prior to transitioning. Clinicians leveraged psychiatric diagnoses as a proxy to predict transition regret, and in some cases delayed or denied medical treatments. We identified cases of patient dissatisfaction with surgical results, and a person who detransitioned. These accounts decouple transition regret and detransition, and no participants endorsed stricter clinical assessments. We traced the clinical work of preventing regret to cisnormativity and transnormativity in medicine which together construct regret as "life-ending", and in turn drives clinicians to apply strategies to mitigate the perceived risk of malpractice legal action when treating trans people, specifically. Yet, attempts to prevent these outcomes contrast with the material healthcare needs of trans people. We conclude that regret and detransitioning are unpredictable and unavoidable clinical phenomena, rarely appearing in "life-ending" forms. Critical research into the experiences of people who detransition is necessary to bolster comprehensive gender-affirming care that recognizes dynamic transition trajectories, and which can address clinicians' fears of legal action-cisgender anxieties projected onto trans patients who are seeking medical care.

Patient perspectives on the implementation of routinised syphilis screening with HIV viral load testing: Qualitative process evaluation of the Enhanced Syphilis Screening Among HIV-positive Men trial

BACKGROUND

Syphilis infections have been on the rise, affecting men living with HIV in urban centres disproportionately. Since individuals in HIV care undergo routine blood testing, HIV clinics provide practical opportunities to conduct regular and frequent syphilis testing. Following the implementation of a routine syphilis testing intervention in HIV outpatient clinics, we conducted a qualitative process evaluation of patient experiences to measure patient acceptability, barriers to implementation, and facilitators of successful uptake.

METHODS

Upon completion of the trial, which took place at four HIV outpatient clinics in Toronto and Ottawa, Canada, we recruited male patients attending these clinics from November 2017 to April 2018. Interviews were conducted on-site and were audio-recorded and transcribed verbatim. All participants provided written informed consent. Interview data were analyzed using grounded theory, assessing qualitative modulators of effective uptake of routinised syphilis testing.

RESULTS

A total of 21 male patients were interviewed. Overall, interviewees found the clinical intervention acceptable, endorsing the practice of routinising syphilis testing alongside regular viral load bloodwork. Some men preferred, based on their self-assessment of syphilis risk, to opt out of testing; we considered this as a potential barrier to uptake of population-wide routinised syphilis testing. Interviewees also identified multiple facilitators of successful uptake, including the de-stigmatising of STI testing as a consequence of the universal nature of routinised testing. Participants recommended a routinised syphilis screening intervention to give patients peace of mind surrounding their sexual health. Participants identified HIV care clinics as comfortable and efficient locations to offer testing.

CONCLUSIONS

Overall, most men were in support of implementing routinised syphilis testing as part of standard HIV care. From the patient perspective, HIV care clinics are convenient places to be tested for syphilis, and the routine approach was viewed to have a de-stigmatisng effect on syphilis testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02019043; registered December 23, 2013.

Integrating trans health knowledge through instructional design: preparing learners for a continent - not an island - of primary care with trans people

In recent years the need to teach primary care providers to better care for transgender and non-binary (trans) patients has garnered significant scholarly and public attention. The alarming why motivating this surge in trans health primary care education has already been firmly established and needs no further comment. Instead, we offer new perspectives on how to do trans health primary care education. From treasured 'trans 101' educational interventions to trans health 'clinical pearls', the prevailing model used to teach primary care learners represents time-limited cultural competency-based education, which we argue creates an isolated education 'island'. In rethinking this approach, we present an introduction to the concepts of knowledge integration and the transfer of learning and apply them to show how trans health knowledge and skills should be structured within existing curricula to support effective learning and application. These instructional design considerations have yet to be extensively explored when teaching primary care learners trans health content and may be critical to building pedagogy that ultimately improves healthcare delivery. We conclude that trans health - and trans patients themselves - must not be treated as an isolated education island of knowledge and practice. Rather, it is the responsibility of educators to design instruction that encourages learners to integrate this knowledge with foundational principles of primary care; building bridges across a continent of primary care practice landscapes in turn.

Patient involvement in medical education: To what problem is engagement the solution?

CONTEXT

Patient and public engagement is gaining momentum across many domains of health care, inclusive of education and research. In this framing, engagement is offered as a solution to a myriad of problems. Yet, the way problems and solutions are linked together may be assumed, rather than made explicit. In the absence of clarity, there is a risk that solutions that may have worked in one domain of health care could falter, or even create new problems, in another.

METHODS

We use a model from organisational studies as a way to make sense of the relationships between the problems, solutions and stakeholders operating in the name of patient and public engagement in health care. The 'garbage can model' is a playfully phrased but meaningful attempt to decipher the complex world of decision making in organisations. We use this model to guide our framing of the solutions of patient engagement practice and the wide range of problem statements that animate all of this activity.

RESULTS

Following a discussion of the complexity of the field of patient engagement, we identify strategies for educators to conceptually weave problem statements, solutions and stakeholders together in mosaics of engagement activity. We further suggest a movement away from considering problems to be solved to thinking about polarities to be navigated.

CONCLUSIONS

As patient engagement becomes more embedded in decision-making spaces in health professions education, we need a better understanding of how decisions are actually made in these organisations. We also need to consider that our most treasured solutions may have an uneasy fit, and some unintended consequences, as they enter new domains of health care. Finally, we advocate for critical approaches not just to the solutions of patient engagement, but to understand problem statements as they are defined, upheld and disrupted through all of this work.

Pay to skip the line: The political economy of digital testing services for HIV and other sexually transmitted infections

The value of digital healthcare has been lauded in Canada at local, provincial, and national levels. Digital medicine is purported to enhance patient access to care while promising cost savings. Using institutional ethnography, we examined the potential for publicly funded digital testing for HIV and other sexually transmitted infections (STI) in Ontario, Canada. Our analyses draw from 23 stakeholder interviews with healthcare professionals conducted between 2019 and 2020, and textual analyses of government documents and private, for-profit digital healthcare websites. We uncovered a "two-tiered" system whereby private digital STI testing services enable people with economic resources to "pay to skip the line" queuing at public clinics and proceed directly to provide samples for diagnostics at local private medical labs. In Ontario, private lab corporations compete for fee-for-service contracts with government, which in turn organises opportunities for market growth when more patient samples are collected vis-à-vis digital testing. However, we also found that some infectious disease specimens (e.g., HIV) are re-routed for analysis at government public health laboratories, who may be unable to manage the increase in testing volume associated with digital STI testing due to state budget constraints. Our findings on public-private laboratory funding disparities thus discredit the claims that digital healthcare necessarily generates cost savings, or that it enhances patients' access to care. We conclude that divergent state funding relations together with the creeping privatisation of healthcare within this "universal" system coordinate the conditions through which private corporations capitalise from digital STI testing, compounding patient access inequities. We also stress that our findings bring forth large scale implications given the context of the global COVID-19 pandemic, the rapid diffusion of digital healthcare, together with significant novel coronavirus testing activities initiated by private industry.

Teaching health professionals how to tailor gender-affirming medicine protocols: A design thinking project

BACKGROUND

Content knowledge surrounding transgender (trans) medicine is currently lacking in the formal medical education curricula. Evidence indicates that the main protocols used to assess and refer trans patients for gender-affirming medicine are misunderstood by health professionals, and require flexible adaptation to achieve health equity and patient-centred care.

APPROACH

A free online educational tool for gender-affirming medicine, The Path to Patient-Centred Care, was developed to teach learners how to adapt assessment protocols. Resource creation was supported by a knowledge translation grant that endorsed design thinking, a human-centred and solutions-focused framework recommended for use in curriculum development.

EVALUATION

The Path to Patient-Centred Care provides learners with information related to key principles of patient-centred care in gender-affirming medicine, including a guide on how to adapt the main assessment protocols to achieve equitable care. The curriculum also includes narratives from trans patients and health professionals that focus on health equity, and a clinical vignette about a complex case, designed to foster critical thinking on medical ethics. Project future directions involve an implementation and evaluation pilot study with a diverse group of continuing professional development medical learners using a mixed-methods program evaluation design.

REFLECTION

The use of design thinking to develop this resource exemplifies a novel approach to curriculum development. By using pedagogical strategies that foster critical reflection, this innovative online education tool strives to teach self-directed learners how to provide care that emphasizes trans people's self-determination and autonomy in medical decision-making.

Correction to: Teaching health professionals how to tailor gender-affirming medicine protocols: A design thinking project

The original version of this article unfortunately contained a mistake. The name of David Rojas Gualdron was presented incorrectly in the author list and in the conflict of interest. The corrected author list is given above. The original article has been ….

Protocols as curriculum? Learning health advocacy skills by working with transgender patients in the context of gender-affirming medicine

Evidenced by leading journals in academic medicine, health professions education has taken up the call to advance equitable healthcare. One pressing area where gaps and inequities are apparent is transgender (trans) people's access to gender-affirming medicine such as hormones and surgeries. Reasons for the dire state of care include education gaps. While specific content knowledge has been identified as lacking in medical school curricula, less research has focused on the complex social practices required of clinicians and educators working in gender-affirming medicine, and how these skills are learned through practice. In order to inform health professions education in this key area of need, we conducted a study to better understand the social practices, and the learning that occurs therein, of gender-affirming medicine. We identified the work processes of 22 clinicians, clinician-educators, trans patients, and clinical care administrators with attention to how policies and protocols influenced practice, learning, and teaching. The results of our study elucidate: (1) that practicing of gender-affirming medicine is strictly dictated by standardized assessment protocols, which serve as a form of curriculum; and (2) how health professionals learn and teach health advocacy as a form of resistance to protocols identified as creating inequities. These findings suggest an opportunity to view protocols-and their inherent limitations-more deliberately as teaching and learning tools, specifically for learning advocacy.