Transgender Care Experiences, Barriers, and Recommendations for Improvement in a Large Integrated Health Care System in the United States

Purpose

Transgender individuals who pursue gender affirmation medical procedures often need to navigate a complex health system and interact with multiple health care providers in primary and specialty care. We sought to better understand patient, provider, and system level barriers to transgender care in a large integrated health care system in California.

Methods

Three 90-min focus groups were conducted with 13 transgender individuals who received specialty care between April and August 2018 in Kaiser Permanente Southern California.

Results

Participants cited common adversities such as misgendering and system-wide insensitivity during health care encounters and low levels of understanding of their transgender experience among primary care providers. Provider-patient relationship improvements were recommended for pre- and postsurgical care and service-provider sensitivity training. Suggestions include better care coordination, reducing redundancy in clearance for specialty care services, and enhancing patient support for navigation of gender affirmation services. Participants requested careful consideration when implementing systemwide routine processes such as using pronouns and names when calling patients in for visits or describing procedures on service invoices.

Conclusions

Education and training programs for improving transgender care competency and enhancing care coordination between primary care and specialty care for transgender patients are warranted. Including transgender voices with lived-experience as active stakeholders in ongoing efforts such as community advisory boards to identify care gaps may facilitate patient-centered and culturally sensitive transgender care and increased patient satisfaction.

Policy Implications

There is a need for systematic training for transgender care competent providers and enhancement of care coordination between primary care and specialty care.

Factors Associated with Experiences of Gender-Affirming Health Care: A Systematic Review

Purpose

Transgender people often pursue gender-affirming health care (GAH), such as hormone therapy and/or surgeries. While research has begun to explore influences on general health care for transgender individuals, less is known about the experiences of GAH specifically. We aimed to systematically review the factors associated with experiences of GAH.

Methods

PubMed, EMBASE, PsycInfo, and Web of Science were systematically searched for relevant literature using a predetermined search strategy. Studies were screened by two researchers to determine whether they fit the inclusion criteria. Following quality appraisal and data extraction, results were thematically analyzed.

Results

Thirty-eight studies were included in the review. Factors associated with experiences of GAH were broadly categorized as follows: (i) sociodemographic factors, (ii) treatment-related factors, (iii) psychosocial factors, and (iv) health care interactions, with health care interactions, in particular, being strong determinants of experience.

Conclusion

Findings suggest that experiences of GAH may be determined by a number of diverse factors, which have implications for understanding how to better support those undergoing transition. In particular, health care professionals play a key role in determining how transgender people experience treatment, which should be considered when providing care for this population.

Mental health practitioners' narratives about gender transition and the role of diagnosis: A qualitative study in the Italian context

In many European Countries, a diagnosis is needed to access the gender transition process, which has sparked debate about whether gender variance should be equated with a psychodiagnosis. This study explores mental health practitioners' perspectives about the implications of using the diagnosis for gatekeeping purposes. Semi-structured interviews were conducted with 11 Italian mental health specialists. The personal positions and interpretative repertoires emerging from the interviews centred on three thematic areas: the diagnosis, the practitioner's role, and the clinical relationship. In relation to the development of health promotion policies, findings underscore the importance of exercising reflexivity, adhering to theory and national and/or international guidelines, and analysing people's needs to ensure that the clinical setting is an affirmative space, especially for non-binary people.

A comparison of perioperative safety for breast augmentation in cis- vs. trans patients

Background

Gender-affirming surgery provides a psychosocial benefit to transgender women. However, increased medical complexity within the transgender population has limited access for some transgender women. This study compared patient population comorbidities and 30-day peri-operative safety following primary augmentation mammoplasty between cis- and transgender women.

Methods

Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database between 2007 and 2016. Transgender patients were identified using ICD-9 &10 codes for gender dysphoria. Categorical variables were compared using chi-squared and Fisher's exact tests while independent t-tests were used for continuous variables. Statistical significance was set at P<0.05.

Results

There were 4,234 breast augmentations identified in cisgender women and 137 in transgender women. Transgender women had a higher frequency of ASA-II and ASA-III patients (P<0.001), diabetes (P<0.001), hypertension (P=0.006), and active smoking status (P<0.001). Despite the higher comorbidity burden and routine use of hormonal therapy, there were no significant differences between populations in major or minor peri-operative complication rates.

Conclusions

Top surgery improves quality of life in transgender women. Despite the more complex pre-operative risk profile in the transgender population, there is no difference in peri-operative safety profiles. Plastic surgeons treating this patient population should consider more liberal surgical indications for reconstructive top surgery compared with cosmetic breast augmentation.

Transgender health: on a world scale

Understanding transgender health on a world scale requires an adequate conceptualisation of gender as an embodied social structure, and an awareness of imbalances in the global economy of knowledge. Four major clusters of health issues are identified for trans groups in the majority, postcolonial world: staying alive in the face of violence and disease, keeping a trans life afloat in practice, facing pressures including rising populism, and making transitions work. Familiar models of professional health care are not adequate to these issues across much of the world; social action and organising are required.

'Bye-bye boobies': normativity, deservingness and medicalisation in transgender medical crowdfunding

Transgender individuals experience multiple barriers to accessing care related to medical transition, including a shortage of providers as well as health insurance programmes that categorically exclude the provision of gender-affirming hormones and surgery. Like people seeking financial support for health care related to illness or injury, many transgender people utilise web-based crowdfunding to help pay for medical transition costs. Although a growing body of research finds that medical crowdfunding individualises the effects of health inequalities, little of this research has focused specifically on trans crowdfunding. A dataset of 410 crowdfunding campaigns for medical transition was created. The majority of online campaigns were used to fund chest surgeries among young, white, binary-identified trans men in the USA. On average, campaigns raise only about 25% of their fundraising goal. Using thematic narrative analysis, I find that campaign narratives exhibit several main themes: trans 101, biological essentialism, insurance access, deservingness, normative transition and notions of progress. These themes illustrate how transgender medical crowdfunding is a response to inequalities but also has the effect of reproducing them.

Incorporating Transition-Affirming Language into Anatomical Pathology Reporting for Gender Affirmation Surgery

Background: The use of inclusive terminology in health records continues to be a challenge for transgender, gender-diverse, and nonbinary peoples. When patients access electronic health records, laboratory results, including pathology reports, are among the most frequently viewed items. There has been limited discussion of transgender care within laboratory medicine, despite its role in providing written pathology reports after gender-affirming surgery. Proposal: This group proposes inclusive diagnostic terminology for pathology reporting and puts forward recommendations for procedural descriptions in the pathology report. Finally, we highlight pathological information that should be included in a report that has future cancer screening or diagnostic consequences.

The Relationship Between Tobacco Use and Legal Document Gender-Marker Change, Hormone Use, and Gender-Affirming Surgery in a United States Sample of Trans-Feminine and Trans-Masculine Individuals: Implications for Cardiovascular Health

PURPOSE

Transgender individuals smoke tobacco at disproportionately higher rates than the general U.S. population, and concurrent use of gender-affirming hormones (estrogen or testosterone) and tobacco confers greater cardiovascular (CV) risk. This study examines the relationship between tobacco use and legal document gender-marker change, and medical/surgical interventions for gender transition.

METHODS

Data came from an Internet-based survey of U.S. trans-feminine (n = 631) and trans-masculine (n = 473) individuals. We used multivariable logistic regression to investigate the relationship between past 3-month tobacco use and legal document gender-marker change, hormone use, and gender-affirming surgery controlling for demographic covariates and enacted and felt stigma.

RESULTS

Compared to trans-feminine participants, trans-masculine individuals reported significantly higher rates of lifetime (74.4% vs. 63.5%) and past 3-month tobacco use (47.8% vs. 36.1%), and began smoking at an earlier age (14.5 vs. 15.5 years). Trans-feminine smokers reported significantly more frequent and heavier use. Adjusting for demographic covariates and enacted and felt stigma, legal document gender-marker change was associated with lower tobacco-use odds among trans-feminine individuals, whereas gender-affirming surgery predicted lower smoking odds among trans-masculine individuals. There were no significant differences in tobacco use by hormone use status.

CONCLUSION

In this study, trans-masculine individuals were more likely to smoke and trans-feminine individuals reported heavier use. It is concerning that individuals receiving hormones did not report lower smoking rates, given the elevated CV risk of this combination. This is a missed opportunity to intervene on a major public health issue and highlights the need for smoking cessation interventions in this population.

Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists

Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.

Advocacy for Gender Affirming Care: Learning from the Injectable Estrogen Shortage

Hormone therapy is medically necessary for many transgender individuals. The U.S. Food and Drug Administration (FDA) and pharmaceutical companies' failure to guarantee a supply of injectable estrogen in 2016 and 2017 for transgender individuals is a violation of their right to comprehensive medical treatment, free of discrimination. A series of advocacy actions eventually led to all formulations of injectable estrogen being restored to market; however, long-term solutions to supply interruptions of injectable estrogen are needed. Long-term solutions should address the lack of federally funded research and, consequently, evidence-based practice on hormone therapy for gender affirmation.

'Part of me already knew': the experiences of partners of people going through a gender transition process

Research has shown that the gender transition of one partner in a relationship can have a significant impact on the non-transitioning partner. This paper explores the experiences of former and current cisgender partners of people making a gender transition. Six participants were recruited via snowball sampling and took part in semi-structured interviews, which were transcribed and analysed using interpretative phenomenological analysis. Three superordinate themes were identified, namely: (1) the shared and ongoing process of learning about a partner's transgender identity; (2) changes in relationships; and (3) impact on self and identity. Findings highlight the constructed nature of gender and sexual identities, and the fluidity with which partners experienced these aspects of their lives. Future research could usefully explore the support needs of partners of transitioning people and the best ways to access and distribute this support.

Barriers to Gender Transition-Related Healthcare: Identifying Underserved Transgender Adults in Massachusetts

Purpose: The present study sought to examine whether individual (e.g., age, gender), interpersonal (e.g., healthcare provider discrimination), and structural (e.g., lack of insurance coverage) factors are associated with access to transition-related care in a statewide sample of transgender adults. Method: In 2013, 364 transgender residents of Massachusetts completed an electronic web-based survey online (87.1%) or in person (12.9%). A multivariable logistic regression model tested whether individual, interpersonal, and structural factors were associated with access to transition-related care. Results: Overall, 23.6% reported being unable to access transition-related care in the past 12 months. In a multivariable model, younger age, low income, low educational attainment, private insurance coverage, and healthcare discrimination were significantly associated with being unable to access transition-related care (all p<0.05). Discussion: Despite state nondiscrimination policies and universal access to healthcare, many of the Massachusetts transgender residents sampled were unable to access transition-related care. Multilevel interventions are needed, including supportive policies and policy enforcement, to ensure that underserved transgender adults can access medically necessary transition-related care.

Rumination as a Marker of Psychological Improvement in Transsexual Women Postoperative

Purpose: This study aimed to analyze rumination levels of transsexual women before and after gender affirmation surgery (GAS). Rumination scores may represent a broader measure of GAS success and an alternative to patient-reported satisfaction, quality of life, well-being, or the presence of “caseness” for anxiety or depression as previously established in the literature.

Methods: Thirty-nine transsexual women were recruited. The participants completed the rumination scale of the Response Styles Questionnaire (RSQ) and were divided into three subsets according to the treatment time.

Results: The rumination scores were lower in the transsexual women who had undergone surgical procedures on primary sexual characteristics and gradually decreased with each additional procedure completed with respect to secondary sexual characteristics.

Conclusion: Rumination appears to comprise an important marker of improvement in post-GAS transsexual women.

Interdisciplinary Transgender Veteran Care: Development of a Core Curriculum for VHA Providers

Purpose: The Veteran's Health Administration (VHA) has created a training program for interdisciplinary teams of providers on the unique treatment needs of transgender veterans. An overview of this program's structure and content is described along with an evaluation of each session and the program overall.

Methods: A specialty care team delivered 14 didactic courses supplemented with case consultation twice per month over the course of 7 months through video teleconferencing to 16 teams of learners. Each team, consisting of at least one mental health provider (e.g., social worker, psychologist, or psychiatrist) and one medical provider (e.g., physician, nurse, physician assistant, advanced practice nurse, or pharmacist), received training and consultation on transgender veteran care.

Results: In the first three waves of learners, 111 providers across a variety of disciplines attended the sessions and received training. Didactic topics included hormone therapy initiation and adjustments, primary care issues, advocacy within the system, and psychotherapy issues. Responses were provided to 39 veteran-specific consult questions to augment learning. Learners reported an increase in knowledge plus an increase in team cohesion and functioning. As a result, learners anticipated treating more transgender veterans in the future.

Conclusion: VHA providers are learning about the unique healthcare needs of transgender veterans and benefitting from the training opportunity offered through the Transgender Specialty Care Access Network–Extension of Community Healthcare Outcomes program. The success of this program in training interdisciplinary teams of providers suggests that it might serve as a model for other large healthcare systems. In addition, it provides a path forward for individual learners (both within VHA and in the community) who wish to increase their knowledge.

A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals

Objectives: To review evidence from prospective cohort studies of the relationship between hormone therapy and changes in psychological functioning and quality of life in transgender individuals accessing hormone therapy over time.

Data Sources: MEDLINE, PsycINFO, and PubMed were searched for relevant studies from inception to November 2014. Reference lists of included studies were hand searched.

Results: Three uncontrolled prospective cohort studies, enrolling 247 transgender adults (180 male-to-female [MTF], 67 female-to-male [FTM]) initiating hormone therapy for the treatment of gender identity disorder (prior diagnostic term for gender dysphoria), were identified. The studies measured exposure to hormone therapy and subsequent changes in mental health (e.g., depression, anxiety) and quality of life outcomes at follow-up. Two studies showed a significant improvement in psychological functioning at 3–6 months and 12 months compared with baseline after initiating hormone therapy. The third study showed improvements in quality of life outcomes 12 months after initiating hormone therapy for FTM and MTF participants; however, only MTF participants showed a statistically significant increase in general quality of life after initiating hormone therapy.

Conclusions: Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning. Prospective controlled trials are needed to investigate the effects of hormone therapy on the mental health of transgender people.

[Legal aspects and the treatment procedure of gender dysphoria in Hungary]

The legal process of gender transition in Hungary had previously been more developed as in most European countries, as the law enabled transsexual people to change their name and gender before or without a medical treatment, which was unique at the time. Over the years, however, lots of European countries developed legal frameworks and accepted international standards of care for the treatment of gender dysphoria that Hungary did not follow. Currently in Hungary there is no consistent legal framework of gender transition, there is no official regulation or guidelines regarding gender transition process, no institution with the obligation to accommodate the process, and there is no nominated specialist in the state health care system whose remit included dealing with transsexual patients. The information on gender transition options both to the professionals and to the patients is limited and incoherent. This paper reviews the legal aspects and clinical management process of gender dysphoria in Hungary. Some issues regarding the Hungarian practice and possible solutions based on examples from the United Kingdom are addressed within the paper.