Strategies used by transmasculine and non-binary adults assigned female at birth to resist transgender stigma in healthcare

Abstract

Background: Transgender stigma is rampant within healthcare systems in the United States. Transgender adults assigned female at birth – including those identifying as transmasculine or non-binary – face unique barriers, such as stigma when accessing sexual and reproductive healthcare labeled as being for “women.” However, transgender and non-binary people are not passive victims to this stigma, and the medical community would benefit from understanding the actions this population takes to resist and reduce transgender stigma in healthcare. Yet, little research has attempted to understand such actions.

Aims: This qualitative study aims to explore how transmasculine and non-binary adults are actively resisting and reducing the impact of transgender stigma in healthcare.

Methods: In-depth semi-structured interviews were conducted with 25 transmasculine and non-binary adults assigned female at birth who were living in a metropolitan area in the mid-Atlantic United States. The research team analyzed qualitative interview data using content analysis.

Results: The 25 participants ranged in age from 21 to 57, with an average age of 33?years old. Six themes were identified related to resisting and reducing transgender stigma in healthcare: (a) using social support; (b) persistence to meet one’s own needs; (c) avoiding mainstream healthcare; (d) advocacy; (e) doing one’s own research; and (f) strategic disclosure of transgender/non-binary identity. We detail how privilege and intersectionality connect to the use of these strategies.

Discussion: Findings indicate there is value in using peer advocates and peer health literacy; in developing and nurturing support groups related to transgender/non-binary health; in developing “allies” employed within the healthcare system; in creating and maintaining lists of culturally responsive health providers and resources about navigating the healthcare system; and in offering trainings related to self-advocacy and health-related activism. These findings can be used to inform future health prevention and intervention efforts with transmasculine and non-binary adults.     

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.     

Non-binary and binary transgender youth: Comparison of mental health,self-harm,suicidality, substance use and victimization experiences

ABSTRACT

?Background: Little research has compared the mental health and victimization experiences of non-binary youth depending on their sex assigned at birth (SAAB), or compared these two groups with binary transgender youth.

Aims: To compare mental health, self-harm and suicidality, substance use and victimization experiences between non-binary and binary transgender young adults, both male assigned at birth (MAAB) and female assigned at birth (FAAB).

Methods: Online survey data from 677 participants from the “Youth Chances” community study of 16 to 25 year olds in the United Kingdom was analyzed, comparing across binary participants (transgender females (n = 105) and transgender males (n = 210)) and non-binary participants (MAAB (n = 93) and FAAB (n = 269)).

Results: Female SAAB participants (binary and non-binary) were more likely to report a current mental health condition and history of self-harm than male SAAB participants (binary and non-binary). Similarly, female SAAB participants (binary and non-binary) were more likely to report childhood sexual abuse than male SAAB participants (binary and non-binary); the reverse pattern was found for lifetime physical assault relating to being LGBTQ. Non-binary MAAB participants were less likely than the other groups to report past suicide attempts and previous help-seeking for depression/anxiety. Binary participants reported lower life satisfaction than non-binary participants. For all four groups, mental health problems, self-harm, suicidality, alcohol use and victimization experiences were generally higher than that of youth in general population studies.

Conclusions: These findings highlight the importance of considering both non-binary versus binary gender identity and SAAB in relation to mental health problems, self-harm, suicidality and substance use in transgender youth. The roles of sexual abuse, other abuse and discrimination in contributing to increased rates of mental illness and self-harm in non-binary and binary transgender individuals, particularly those who were assigned female at birth, relative to those assigned male, require investigation.     

Mental health and quality of life in non-binary transgender adults: a case control study

Abstract

Background: The social challenges that non-binary people experience, due in part to social intolerance and the lack of validation of non-binary gender identities, may affect the mental health and quality of life of this population. However, studies that have distinguished between non-binary and binary transgender identities are lacking.

Aim: To compare the mental health and quality of life of a community sample of non-binary transgender adults with controls (binary transgender people and cisgender people) matched on sex assigned at birth.

Method: A total of 526 participants were included. Ninety-seven were classified as non-binary and were compared with two control groups: 91 people classified as binary and 338 cisgender people. Only transgender people not on gender affirming hormone treatment or who had not undergone gender affirming surgery were included. Participants were invited to complete an online survey that included mental health and quality of life measures.

Results: Non-binary people reported significantly better mental health than binary transgender people, but worse than cisgender people. Overall, there were no significant differences in quality of life between non-binary and binary transgender participants assigned male at birth and transgender females, but non-binary assigned males at birth had better scores on the psychological and social domains of quality of life than transgender males. Quality of life was better across all domains in cisgender people than transgender groups.

Conclusion: There is an inequality with regard to mental health and quality of life between non-binary (and binary) transgender people and the cisgender population that needs to be addressed. The better mental health scores in non-binary people may reflect lower levels of body dissatisfaction among the non-binary population. Mental health problems and poor quality of life are likely to have social causes and hence legislative measures and broader government-led inclusive directives should be put in place to recognize and to validate non-binary identifying people.     

Supporting families of transgender children/youth: Parents speak on their experiences,identity, and views

ABSTRACT

Background: Transgender children/youth demonstrate the best possibility for resilience and positive mental health when they are part of an affirming and supportive family. To optimize families in supporting transgender children/youth, parents/caregivers need to be supported. Transgender children/youth and their families regularly navigate a myriad of challenges through society.

Aims: Within the extant literature on transgender children and youth, relatively little attention is focused on the experiences of parents/caregivers and how their close family relationships are affected. The present qualitative study addresses this gap in knowledge through its exploration of the experiences, identities, and views of parents/caregivers of transgender children/youth.

Method: The study is longitudinal and this article represents the first wave. Fourteen parents of 12 transgender children/youth, aged 6–17, participated in in-depth semistructured interviews. Participants were recruited via social media and at an on-site conference for transgender youth and their families. All children/youth had socially transitioned. Those who were eligible for puberty suppression and/or hormone therapy were receiving those. The interviews were inductively coded for themes by two coders using the constant comparative method.

Results: Participants' reports on their experiences yielded three themes: (1) transgender issues as the family's focus; (2) proactivity, child-focused: preemptive actions to prevent adverse consequences; and (3) self-care. These themes included subthemes on effective coping strategies to mitigate struggles. Three themes related to participants' identity and views emerged: (1) identity reformation, (2) self-evaluation, and (3) views of future. These themes included subthemes that reflected how participants viewed themselves, their child, and the future.

Discussion: A transgender identity in one family member affects all household members. Parents/guardians may experience guilt and self-doubt over decisions. Factors that may improve outcomes with extended family and schools include families' preemptive dissemination of information on transgender identities and explicating expectations of respect and nonintrusion. Ingrained traditions may force life-altering decisions.     

Contemporary transgender health experience and health situation in prisons: A scoping review of extant published literature (2000–2019)

Abstract

Background: Many jurisdictions globally have no specific prison policy to guide prison management and prison staff in relation to the special needs of lesbian, gay, bisexual and transgender (LGBT) prisoners despite the United Nations for the Treatment of Prisoners Standard Minimum Rules and the updated 2017 Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity. Within LGBT prison groups, transgender people represent a key special population with distinct needs and rights, with incarceration rates greater than that of the general population, and who experience unique vulnerabilities in prisons.

Aims/Method: A scoping review was conducted of extant information on the transgender prison situation, their unique health needs and outcomes in contemporary prison settings. Fifty-nine publications were charted and thematically analyzed.

Results: Five key themes emerged: Transgender definition and terminology used in prison publications; Prison housing and classification systems; Conduct of correctional staff toward incarcerated transgender people; Gender affirmation, health experiences and situational health risks of incarcerated transgender people; and Transgender access to gender-related healthcare in prison.

Conclusions: The review highlights the need for practical prison based measures in the form of increased advocacy, awareness raising, desensitization of high level prison management, prison staff and prison healthcare providers, and clinical and cultural competence institutional training on transgender patient care. The review underscores the need to uphold the existing international mandates to take measures to protect incarcerated transgender people from violence and stigmatization without restricting rights, and provide adequate gender sensitive and gender affirming healthcare, including hormone therapy and gender reassignment.     

‘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.     

Parental desire and fertility preservation in assigned male at birth transgender people living in Belgium

Abstract

Introduction: Transgender people who chose to proceed with gender affirming hormonal and/or surgical therapy, may face reduced options for fulfilling their parental desire in the future. The ideas and concerns of adult transgender people regarding fertility preservation and parental desire have never been reported in a large, non-clinical sample of assigned male at birth (AMAB) transgender people.

Methods: A web-based survey on fertility and parenthood in (binary and non-binary) transgender people was conducted in Belgium. AMAB people were selected for this analysis.

Results: We included 254 AMAB persons, of which 196 (77.2%) self-identified as transgender women (TW), 14 (5.5%) as cross-dressers and 44 (17.3%) as gender non-binary (GNB) people. Fifty-five (21.6%) respondents had a current/future parental desire, parental desire was already fulfilled in 81 (31.9%) and not present in 57 people (22.4%) (other: 19.2%). TW were more likely to express a parental desire, compared to GNB people and cross-dressers (P?=?0.004). In total, 196 AMAB people previously sought medical assistance, of which 30 (15.3%) considered the loss of fertility due to the transitioning process undesirable. The majority (68.2%) did not want fertility preservation (FP). Fourteen people (9.8%) had proceeded with FP. The main reasons not to proceed with FP included not feeling the need (70; 68.0%), not desiring a genetic link with (future) child(ren) (20; 19.4%) and having to postpone hormone treatment (15; 14.6%). TW were more likely to have a parental desire and to have cryopreserved or to consider cryopreserving gametes, compared to GNB people.

Conclusion: Parental desire and FP use were lower in the current non-clinical sample than in previous research on clinical samples. This can possibly be explained by the barriers transgender people face when considering fertility options, including postponing hormone therapy. Also, GNB persons have different needs for gender affirming treatment and FP.     

Taiwanese speech–language therapists’ awareness and experiences of service provision to transgender clients

Background: One of the most influential factors that affect the quality of life of transgender individuals is whether they can be perceived by others to “pass” in their felt gender. Voice and communication style are two important identifying dimensions of gender and many transgender individuals wish to acquire a voice that matches their gender. Evidence shows that few transgender individuals access voice therapy, and that this is caused by their concerns about stigmatization or negative past experiences within healthcare services. In order to address the negative experiences faced by transgender populations we need a better understanding of healthcare services’ current levels of knowledge and LGBT awareness. Some studies of Speech–Language Therapists’ (SLTs’) experience and confidence working with transgender individuals have recently been undertaken in the United States (US). However, little research has been carried out in Asia.

Aims: To investigate Taiwanese SLTs’ knowledge, attitudes and experiences of providing transgender individuals with relevant therapy.

Method: A cross-sectional self-administered web-based survey hosted on the Qualtrics platform was delivered to 140 Taiwanese SLTs.

Results: Taiwanese SLTs were, (i) more familiar with the terminology used to address “lesbian, gay, and bisexual groups” than with “transgender” terminology, (ii) generally positive in their attitudes toward transgender individuals, and (iii) comfortable about providing clinical services to transgender clients. However, the majority of participants did not feel that they were sufficiently skilled in working with transgender individuals, even though most believed that providing them with voice and communication services fell within the SLT scope of practice.

Conclusion: It is important for clinicians to both be skilled in transgender voice and communication therapy and to be culturally competent when providing services to transgender individuals. This study recommends that cultural competence relating to gender and sexual minority groups should be addressed in SLTs’ university education as well as in their continuing educational programs.     

Using circular questions to explore individual family member experiences of youth gender dysphoria in Australia

Abstract

Background: The number of young people reporting gender dysphoria is increasing worldwide, with gender dysphoria known to affect everyone in the family in unique ways. Previous research has highlighted the importance of family support and understanding; however, much less is known about individual and collective family member experiences, particularly for siblings under the age of 18?years.

Aims: This study sought to identify, describe and interpret individual family member experiences of youth gender dysphoria using semi-structured interviews, incorporating circular questioning, within a whole of family, clinical and wider social context.

Methods: Thirty-five individual family members living in Australia (nine young people aged 12-17?years experiencing gender dysphoria, 10 mothers, eight fathers, and eight siblings aged 11-17?years) were interviewed, exploring positive and negative experiences of youth gender dysphoria, within and outside of the family. Family relationships, support and healthcare experiences were also explored.

Results: All participants reported a mixture of positive and negative experiences of youth gender dysphoria. Levels of acceptance tended to change with the duration of transition, with most family members adapting with time. Siblings reported mixed experiences within the same family, with some struggling to adapt. Most family members felt that including the whole family in the healthcare of the young person was important, although dependent on individual circumstances and family context. Specialist gender care experiences were unanimously positive, although services were considered difficult to access.

Discussion: Family members reported shared and individual positive and negative experiences of youth gender dysphoria across social contexts. Accepting and facilitating gender transition for young people appeared to improve individual and family functioning. Most participants valued a whole of family approach within specialist healthcare. The use of circular questioning in the study helped dispel assumptions and facilitated curiosity for others’ experiences in the family.     

Housing insecurity and intersecting social determinants of health among transgender people in the USA: A targeted ethnography

Abstract

Background: Housing is an important social determinant of health (SDOH). Transgender people face a unique blend of discrimination and compromised social services, putting them at risk for housing insecurity and associated public health concerns.

Aims: This targeted ethnography explores housing insecurity as a SDOH among transgender people in the U.S.

Methods: In-depth interviews were conducted with transgender people (n?=?41) throughout the U.S.A., identified through purposive sampling. A semi-structured guide was used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes.

Results: Responses revealed pervasive housing insecurity and inter-related challenges. Respondents discussed how intersecting identities create unique constellations of vulnerability, which “intersect like a star.” Financial insecurity and interpersonal rejection were lead housing insecurity causes, often resulting in psychological strain, which was sometimes addressed with substances and sexual risk-taking. These factors were cyclically accompanied by financial and employment insecurity and a cascade of unmet social needs. Social support facilitated coping.

Discussion: Findings support increasing transgender housing security intervention resources that address intersecting and cyclical discrimination, trauma, housing, employment, and health issues.     

Experiences of transgender prisoners and their knowledge,attitudes, and practices regarding sexual behaviors and HIV/STIs: A systematic review

Background: Despite transgender people being more visible in prison systems, research suggests they are at higher risk of experiencing sexual violence compared to other prisoners. Research also suggests that transgender prisoners experience harassment, and physical and sexual assault by fellow prisoners, and prison officers who lack transgender-specific health knowledge. There exist no systematic reviews on the experiences of transgender people in prisons. This review aims to fill this research gap. The following question developed in consultation with transgender, sexual health/HIV and corrective services stakeholders has guided the systematic review: What are transgender and gender-diverse prisoners’ experiences in various prison settings and what are their knowledge, attitudes and practices regarding sexual behaviors and HIV/STIs?

Methods: The review followed the PRISMA guidelines and searches were conducted in four databases for the period of January 2007 to August 2017. Studies were assessed against predetermined inclusion and exclusion criteria. Included studies were peer-reviewed, written in English with online full-text availability and reported data on transgender and gender-diverse prisoner experiences relevant to the research question.

Results: Eleven studies (nine qualitative, one quantitative, one mixed-methods; nine in USA, two in Australia) met the criteria for review. Four studies were of high quality, six were of good/acceptable quality, and one study was of modest quality. Transgender and gender-diverse prisoners reported a range of challenges which included sexual assault, discrimination, stigma, harassment, and mistreatment. Information on their sexual health and HIV/STIs knowledge, attitudes, practices is in short supply. Also, their lack of access to gender-affirming, sexual health/STIs and mental health services is commonplace.

Conclusions: The experiences of transgender prisoners as reported in this review are almost uniformly more difficult than other prisoners. Their “otherness” is used as a weapon against them by fellow prisoners through intimidation and violence (including sexual) and by prison officers through neglect and ignorance.     

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 Gender Congruence and Life Satisfaction Scale (GCLS): Development and validation of a scale to measure outcomes from transgender health services

Background: It is vital that the treatment offered at transgender health services can be evaluated to ensure a high quality of care. However, the tools currently used to evaluate treatment at transgender health services are limited by mainly focusing on mental health or because they have been developed for binary transgender people only. This study therefore aimed to develop and validate a tool that addresses these limitations. The Gender Congruence and Life Satisfaction Scale (GCLS) was developed through reviewing the literature, conducting interviews with transgender people, and holding discussions with experts working in transgender healthcare. An initial pool of items was developed and feedback on these was obtained. The tool was then validated.

Method: For the validation of the tool, a total of 789 participants (451 transgender [171 transgender females, 147 transgender males, 133 people identifying as non-binary], and 338 cisgender [254 females, 84 males]) were recruited from the United Kingdom to test the factor structure and validity of the GCLS.

Results: Exploratory factor analysis retained 38 items which formed seven subscales (psychological functioning; genitalia; social gender role recognition; physical and emotional intimacy; chest; other secondary sex characteristics; and life satisfaction). These seven subscales were found to have good internal consistency and convergent validity. The GCLS was also found to be capable of discriminating between groups (e.g., people who have and have not undergone gender affirming medical interventions). Transgender and cisgender subscale norms are provided for the GCLS.

Conclusion: The GCLS is a suitable tool to use with the transgender population to measure health-related outcomes for both clinical and research purposes.     

A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children

ABSTRACT

Background: It has been widely suggested that over 80% of transgender children will come to identify as cisgender (i.e., desist) as they mature, with the assumption that for this 80%, the trans identity was a temporary “phase.” This statistic is used as the scientific rationale for discouraging social transition for pre-pubertal children. This article is a critical commentary on the limitations of this research and a caution against using these studies to develop care recommendations for gender-nonconforming children.

Methods: A critical review methodology is employed to systematically interpret four frequently-cited studies that sought to document identity outcomes for gender-nonconforming children (often referred to as “desistance” research).

Results: Methodological, theoretical, ethical, and interpretive concerns regarding four “desistance” studies are presented. The authors clarify the historical and clinical contexts within which these studies were conducted to deconstruct assumptions in interpretations of the results. The discussion makes distinctions between the specific evidence provided by these studies versus the assumptions that have shaped recommendations for care. The affirmative model is presented as a way to move away from the question of, “How should children's gender identities develop over time?” toward a more useful question: “How should children best be supported as their gender identity develops?”

Conclusion: The tethering of childhood gender diversity to the framework of “desistance” or “persistence” has stifled advancements in our understanding of children's gender in all its complexity. These follow-up studies fall short in helping us understand what children need. As work begins on the 8th version of the Standards of Care by the World Professional Association for Transgender Health, we call for a more inclusive conceptual framework that takes children's voices seriously. Listening to children's experiences will enable a more comprehensive understanding of the needs of gender-nonconforming children and provide guidance to scientific and lay communities.