Provider quality and barriers to care for transgender people: An analysis of data from the Wisconsin transgender community health assessment

Background: Transgender people in the United States often lack access to high-quality health care.

Methods: A group of researchers and transgender people came together in a community-based participatory research process to survey transgender Wisconsinites about their health care experiences. A multiple regression analysis of survey data was used to evaluate the association between barriers to health care, gender identity, and quality of medical and mental health care provider.

Results: Seventy-seven respondents were included in this analysis. Transmasculine respondents were more likely than transfeminine respondents to report barriers to high-quality health care, but having a high-quality medical or mental health care provider was associated with reporting fewer barriers to care across the entire sample.

Discussion: This community-based study suggests that health care providers play a key role in facilitating access to care for transgender Wisconsinites in the USA.     

Implementing Trauma-Informed Care in Primary Medical Settings: Evidence-Based Rationale and Approaches

ABSTRACT

Chronic stress stemming from trauma exposure and posttraumatic stress disorder (PTSD) leads to many health problems that are typically seen by primary care providers. Unfortunately, providers rarely identify trauma as the root cause of patient difficulties. The present paper provides an evidence-based rationale for implementing trauma-informed care principles and processes into medical primary care systems. Beginning with a review of prevalence of trauma exposure and PTSD in primary care clinics, this article elucidates relationships between trauma exposure and behavioral and medical health problems, as well as clinical and physiological pathways that lead from trauma exposure to illness. The article concludes with exposition of trauma-informed interventions that can be implemented in primary care clinics, and discussion of future directions.     

Ethical,Legal, and Psychosocial Issues in Care of Transgender Adolescents

SUMMARY

Complete care for transgender adolescents must be considered in the context of a holistic approach that includes comprehensive primary care as well as cultural, economic, psychosocial, sexual, and spiritual influences on health. Not all transgender adolescents have gender dysphoria or wish to undergo sex reassignment. In this article we focus on general care of transgender adolescents by the non-specialist working in primary care, family services, schools, child welfare, mental health, and other community settings.     

‘If they didn’t support me,I most likely wouldn’t be here’: Transgender young people and their parents negotiating medical treatment in Australia

Abstract

Background: It is increasingly recognized that transgender young people require affirming medical care, however the provision of such care may be mitigated by the availability of services and the views of parents.

Aims: This study aimed to explore the views of Australian transgender young people (aged 11–17) and their parents with regards to medical treatment.

Methods: Ten qualitative interviews were conducted with parent-child dyads in two Australian states. Thematic analysis was undertaken on responses to interview questions related to family relationships, views about medical treatment (specifically hormone blockers and hormones), and the relationship between medical treatment and sense of self.

Results: Themes developed focused on the importance of strong supportive parent-child relationships, the meaning of and access to hormone blockers, and the meaning of and access to hormones.

Discussion: The paper concludes by discussing the implications of the findings for clinical services, particularly in relation to supporting parents to be affirming of a transgender child, the need to prepare transgender young people and their parents for the passage of time in regards to medical treatment, and the need to focus on expectations in regards to sense of self in relation to medical treatment.     

Health and Social Services for Male-to-Female Transgender Persons of Color in San Francisco

SUMMARY

This article presents findings from an investigation of health needs, service utilization, and perceived barriers to services among male-to-female (MtF) transgender persons of color in San Francisco. Focus groups (n = 48) and survey interviews (n = 332) were conducted with convenience samples recruited from the community. Participants reported a range of health and social services needed during the previous year, with African-Americans and Latinas showing particularly strong service needs. Rates of utilizing services were high for basic health care but lower for social services, substance abuse treatment, psychological counseling, and gender transition-related medical services. No significant ethnic group differences in health service utilization were found. Qualitative findings evinced the call for transgender-specific programs and advanced provider training on transgender issues such as hormone use, gender transition, HIV/ AIDS care and prevention, substance abuse, and mental health problems.     

The Primary Care Health System as a Core Resource in Response to Terrorism

Abstract

Living through a terrorist event or under threat of attack affects both mental and physical health. A nation's primary care system plays a critical role under such circumstances. This article reviews the American experience after September 11, 2001 and advocates for integration of mental and physical health services in primary care settings as a key counter-terrorism strategy. Americans put their trust in primary care providers. The nation's healthcare system must develop and implement a strategy that informs and supports primary care providers in meeting the mental health needs of a nation confronted by terrorism.     

Access to Health Care for Transgendered Persons: Results of a Needs Assessment in Boston

SUMMARY

The transgender community is a population group that has experienced an increase in visibility, with only a small, concomitant increase in understanding. This study reports on four focus groups, in which 34 transgendered individuals discussed their experiences and interactions with the health care system.

The specific aims of the study were as follows:

• Identify the health needs of transgender and transsexual (TG/TS) individuals;

• Hear the experiences and perceptions of TG/TS individuals who are using the current health care system;

• Identify any barriers to obtaining services, support and/or resources;

• Assess the extent to which health care providers and systems are able to offer sensitive, high quality and user friendly services that meet TG/TS consumers' needs; and

• Identify ways that health care services can be enhanced to better meet the needs of the target population.

What the study found was a system that was anything but high quality in meeting the needs of TG/TS individuals. Ignorance, insensitivity and discrimination appear to be the norm. Specifically, the focus groups found the following:

• Transgendered and transsexual persons frequently encounter providers who will not treat them and blatantly say so. There is a need for education and a change in anti-discrimination law needed to change this.

• The lack of provider training on transgender issues creates insensitivity to simple issues of respect for trans people. One example is the unwillingness to address TG/TS people by the pronoun preferred by the patient/client.

• Many providers lack the knowledge to adequately treat many of the routine health care needs of TG/TS individuals when such treatment relates to issues of hormone use, gynecological care, HIV prevention counseling, or other concerns related to gender or sexuality.

• Providers frequently refer to trans issues in unrelated health care situations such as setting a broken bone, filling a cavity or treating a cold. Greater familiarity with the health care needs of the trans population would reduce such incidents.

• Mental health and substance abuse treatment providers need additional training in order to work cooperatively with TG/TS clients to identify when gender issues are or are not relevant to specific mental health or substance abuse treatment episodes. Sometimes gender issues are central to mental health or substance abuse treatment, sometimes they are peripheral and sometimes they are unrelated.

• Discrimination in health insurance is the rule, not the exception. There is a need for education to encourage policy changes on the part of insurers and public policy changes on the part of legislators and regulators.

     

Counseling and Mental Health Care for Transgender Adults and Loved Ones

SUMMARY

Increasingly, transgender individuals and loved ones (partners, family, and friends) are seeking assistance from mental health professionals working in the community rather than in university or hospital-based gender identity clinics. Drawing on published literature specific to transgender mental health, interviews with expert clinicians, the authors' clinical experience, and three key guiding principles (a transgender-affirmative approach, client-centered care, and a commitment to harm reduction), we suggest protocols for the clinician providing mental health services in the community setting. Practice areas discussed include assessment and treatment of gender concerns, trans-specific mental health issues, and trans-specific elements in general counseling of transgender individuals and their loved ones.     

Common barriers to healthcare for transgender people in the U.S. Southeast

Abstract

Background: Transgender and non-binary people are more likely to face barriers to healthcare than their cisgender counterparts. The majority of work in this area centers on the experiences of transgender people in northern cities and urban enclaves, yet over 500,000 transgender people live in the U.S. Southeast.

Aims: The purpose of this study is to explore barriers to healthcare among transgender people in the U.S. Southeast.

Methods: The research team conducted four 120-minute focus groups (eligibility criteria: 18?years or older, self-identify as transgender, live in the U.S. Southeast). Participants completed a demographic questionnaire prior to the start of the focus group. Each focus group explored access to and experiences of receiving basic healthcare as a transgender person in the U.S. Southeast. Established qualitative methods were used to conduct the focus groups and data analysis.

Results: Participants (n?=?48) ranged in age from 19 to 65, with the majority identifying as trans women (43.8%) and non-binary (33.3%). The sample was racially diverse: White (50%), Black (37.5%), and Latinx or Multiracial (12.5%). Multiple barriers to care were identified: (1) fear and mistrust of providers; (2) inconsistency in access to healthcare; (3) disrespect from providers; and, (4) mistreatment due to intersecting experiences of gender, race, class, and location.

Discussion: Transgender Southerners face barriers to care at the structural, cultural, and interpersonal levels. The study results have implications for researchers, as well as providers, practices, and health care systems throughout the region.     

Exploring emotions in dialog between health provider,parent and child. An observational study in pediatric primary care

IntroductionThis paper is part of the theoretical thread of health psychology and it presents a study aimed to recognize information useful to implement psychological interventions finalized to personalize medical treatments and engage users in pediatrics.ObjectiveIn this paper is presented an observational study aimed to explore doctor-patient dialog about worries in pediatric primary care; it has been carried out identifying dialogical interaction patterns, or typical dialog between health providers, parent and child.MethodWe documented conversations in 265 visits; we audio-recordered, transcribed and analyzed them with Verona Coding Definitions of Emotional Sequences. Dialogs between participants were analyzed one by one. Frequencies of emotions’ signals (cues/concerns) and responses were analyzed through Redundancy Analysis, aimed to establish a quantitative relationship between these pair of groups of variables considering the asymmetrical relationship between them.ResultsSix “Dialogical Interaction Patterns” were obtained by interpreting these relationships; they show dialogs mainly aimed at obtaining information useful for diagnosis and treatment, with a limited exploration of worries or issues related to the condition of the child. Pediatric conversations seem to be characterized by a very high attention to cognitive aspects of medical questions with a poor consideration of emotions as useful information to medical practice.ConclusionsThese dialogs seem to ensure the rapidity and the efficiency of medical visits. Nevertheless, it could be useful to implement psychological interventions to achieve an enrichment of the dialog between participants, helping them to recognize users’ emotions as useful to define shared medical strategies.     

The Challenge of Integrated Care for Mental Health: Leaving the 50 minute hour and Other Sacred Things

A growing body of research has demonstrated the effectiveness of integrating mental/behavioral healthcare with primary care in improving health outcomes. Despite this rich literature, such demonstration programs have proven difficult to maintain once research funding ends. Much of the discussion regarding maintenance of integrated care has been focused on lack of reimbursement. However, provider factors may be just as important, because integrated care systems require providers to adopt a very different role and operate very differently from traditional mental health practice. There is also great variability in definition and operationalization of integrated care. Provider concerns tend to focus on several factors, including a perceived loss of autonomy, discomfort with the hierarchical nature of medical care and primary care settings, and enduring beliefs about what constitutes “good” treatment. Providers may view integrated care models as delivering substandard care and passively or actively resist them. Dissemination of available data regarding effectiveness of these models is essential (e.g. timeliness of treatment, client satisfaction). Increasing exposure and training in these models, while maintaining the necessary training in traditional mental health care is a challenge for training at all levels, yet the challenge clearly opens new opportunities for psychology and psychiatry.     

Non-binary youth: Access to gender-affirming primary health care

ABSTRACT

Background: Transgender (trans) youth who identify outside the gender binary are a growing subpopulation. In this article, we document differences in access to gender-affirming health care between binary and non-binary identified trans youth and explore ways of meeting the health needs of non-binary youth within primary care settings.

Methods: The Canadian Trans Youth Health Survey is a national online survey of trans youth, 14–25 years, conducted in 2013–2014. Among the 839 participants who responded to gender identity items in the survey, 41% identified as non-binary. We compared demographic, health outcome, and health care access responses between non-binary and binary (trans girls/women and trans boys/men) youth.

Results: Non-binary and binary youth were similar in most demographics, including age, geographic distribution, and ethnocultural backgrounds, however a larger proportion (82%) of non-binary youth were assigned female at birth. Older non-binary youth (aged 19–25) were significantly more likely to forego needed healthcare than older binary youth; no significant differences were found between younger (14–18) non-binary and binary youth in foregoing healthcare. Overall, non-binary youth (13%) were significantly less likely than binary youth (52%) to access hormone therapy, but they were more likely than binary youth to report experiencing barriers to accessing hormone therapy when needed.

Conclusions: Non-binary trans youth in Canada report challenges in accessing needed gender-affirming healthcare. Primary care providers are well-situated to integrate a broad range of gender-affirming care services into practice in order to address the unique needs of non-binary youth. Future research is warranted to explore experiences of non-binary youth related to barriers to care and to explore how services can be designed and delivered to better meet the needs of non-binary youth seeking gender-affirming primary care.     

The Health and Social Service Needs of Transgender People in Philadelphia

SUMMARY

Two Philadelphia-based HIV service organizations and a local university collaborated on a study of health and social service needs of transgender people. Transgender people were the primary resource for the development of the needs assessment survey. In this article, the survey development process, including two discussion groups and two focus groups, are described. Findings on barriers to care, violence, perception of public safety and comfort, suicide and health and social service needs are presented. Total sample size was 81, with 49 male-to-female and 32 female-to-male transgender individuals. Most (68%) were African American. About half of the respondents had thought about attempting suicide. High levels of violence were reported, especially among male-to-females. Health and social service needs included job training/work, dental care, health care, legal services, transportation, education and housing.     

Disparities in access to family physicians among transgender people in Ontario,Canada

Background: Informed by the Gelberg-Andersen behavioral model for vulnerable populations, this study examined the prevalence of and factors associated with not having a family physician among transgender (trans) people in Ontario, Canada.

Methods: Data were drawn from a respondent-driven sampling (RDS) survey of trans Ontarians age 16 and above (n = 433) conducted between 2009 and 2010. All analyses were weighted using RDS II methods. Prevalence ratios were estimated using average marginal predictions from logistic regression models.

Results: An estimated 17.2% (95% CI, 11.0 to 22.9) of trans Ontarians (median age = 28.7, 77.3% White) did not have a regular family physician. In multivariable analyses accounting for other predisposing and need-related factors, transfeminine persons (trans women and non-binary persons assigned a male sex at birth) who were Indigenous and/or persons of color were less likely than other transfeminine persons to have a family doctor. In addition, trans persons who were homeless or had unstable housing were less likely to have a family doctor than those who were adequately housed.

Conclusions: These results provide the first quantitative evidence of health disparities by race and gender within a Canadian transgender population and suggest a social gradient in access to care within Ontario's “universal health insurance” system.     

Exploring rates of transgender individuals and mental health concerns in an online sample

Background: Prevalence estimates of adults identifying as transgender are scarce, particularly in the United States. Method: The current study endeavored to estimate the prevalence of individuals identifying as transgender in a large online sample of adult U.S. residents (n = 6,727) and compare the prevalence of common mental health disorders (depression, anxiety, attention-deficit/hyperactivity disorder) and the age of onset for individuals identifying as men or women versus those identifying as transgender. Results: The prevalence estimate of individuals identifying as transgender was 0.8%. Individuals identifying as transgender were significantly more likely than individuals identifying as men or women to report having had a single diagnosis or co-occurring diagnoses for all three disorders examined. Additionally, transgender individuals were more likely than individuals identifying as men or women to receive a diagnosis of anxiety or depression at a younger age. Conclusion: Given the prevalence of transgender individuals and the associations with common mental health conditions, clinicians must be informed and competent to care for their clinical needs. This study introduces online crowdsourcing resources as a potentially fruitful option for reaching and researching gender diversity.     

A Call for Mental Health Treatment in Incarcerated Settings with Transgender Individuals

Abstract

The U.S. correctional system has become the epicenter for public health and mental health crisis. This article discusses literature documenting incarcerated transgender individuals’ mental health treatment. The severity of mental illness treatment issues within the system amongst transgender and other LGBTQ?+?individuals, clearly displays the need for interventions tailored to this population. Recommended interventions are centered around post traumatic response and cater to those who exist in marginalized populations with consideration given to the significance of family strain and support. Overall, there is a need for a shift in mindset and available services to treat incarcerated transgender individuals.     

Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.