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.     

Health-related quality of life in transgender adolescents: Associations with body image and emotional and behavioral problems

Background: Transgender adolescents who apply for treatment often experience a marked increase in body-related distress when entering puberty, accompanied by internalizing problems and poor peer relations. Although adolescence is a time of considerable psychosocial and physical change, generally associated with a decline in health-related quality of life (HRQoL), research on HRQoL in transgender youth and possible predictors is sparse. This study thus aims to explore the predictive value of body image factors and emotional and behavioral problems for HRQoL.

Methods: This cross-sectional one-group observational study was carried out at the Child and Adolescent psychiatric department (Gender Identity Service) in Hamburg, Germany. A sample of n = 126 (103 trans male and 23 trans female) adolescents, who were referred for counseling and/or treatment completed different standardized instruments before undergoing any sort of treatment. Firstly, five dimensions of HRQoL were explored in transgender adolescents and secondly, a linear regression model was applied to assess the impact of body image and emotional and behavioral problems on overall HRQoL.

Results: HRQoL was generally impaired in transgender adolescents compared to norm scores, especially with regard to aspects of psychological and physical well-being. Linear regression analysis revealed that greater internalizing problems and less body satisfaction significantly predicted lower HRQoL outcomes.

Conclusions: Impaired HRQoL may be explained by high degrees of internalizing problems and low body satisfaction. Thus, one important aim of mental health professionals working with youth should be to provide appropriate treatment and counseling options that may contribute to overall well-being in the long-term.     

Care of the transgender or gender-nonconforming patient undergoing in vitro fertilization

Background: Assisted reproductive technologies, including in vitro fertilization (IVF), can be utilized for fertility preservation and family building in the transgender and gender-nonconforming population.

Methods: This is a retrospective case series from an academic tertiary care center.

Results: We present three couples with a transgender or gender-nonconforming member who pursued IVF to build their families. The first case involves a transgender man who suspends hormone therapy to undergo IVF. The second involves a transgender woman who uses her previously banked sperm to undergo IVF with her wife. The third involves a gender nonbinary patient and their cisgender wife who create and transfer embryos from both partners.

Conclusion: IVF can provide unique family-building opportunities to transgender and gender-nonconforming patients, and providers should seek to broaden their clinical experience with this population.     

Prevalence of anxiety symptoms and disorders in the transgender population: A systematic review of the literature

Introduction: Anxiety disorders are the most common mental illness in the general population, affecting 18% of the population in the United States (12 months prevalence) and 13.6% in Europe (life time prevalence). Several studies have also described high rates of anxiety disorders and symptoms of anxiety among the transgender population. There is, however, a great variation of results (particularly related to gender prevalence), and few studies have described the type of anxiety disorders specific to the transgender population.

Aim: To collect and critically appraise the information from the available studies describing prevalence rates of anxiety disorders and symptoms.

Results: A total of 25 cross-sectional (n = 17) and longitudinal (n = 8) studies were found. Cross-sectional studies described higher prevalence rates of anxiety symptoms in the transgender group than in the cis population. The prevalence of anxiety disorders range from 17% to 68%. The most common anxiety disorders found were specific phobias, social phobias, panic disorders, and obsessive-compulsive disorders. Most of the large studies suggest higher levels of anxiety symptoms and disorders in transgender men compared with transgender women; however, considerable variation in results was found.

Conclusions: The findings identified that there is considerable variation in anxiety disorders and symptoms among transgender people attending transgender health services. These findings are likely to be the result of the tools used, the lack of matching controls, and the lack of homogeneity of the group studied. Overall this review indicates high levels of anxiety symptoms and disorders among transgender people attending gender services, primarily (but not exclusively) before commencement of cross-sex hormone treatment. Anxiety disorders related to social interaction (such as social anxiety) and panic attack appear to be particularly common, however more rigorous studies to confirm those findings are needed.     

Investigating the social integration and wellbeing of transgender individuals: A meta-synthesis

Introduction: There is growing literature about the experiences of social integration and wellbeing of transgender individuals. However, there has been no synthesis across this body of research. Accordingly, the aim of this review was to aggregate, interpret, and synthesize findings from qualitative studies pertaining to the social integration and wellbeing of transgender individuals.

Methods: This study synthesized findings from 18 qualitative and mixed method studies which had explored the social integration and wellbeing of transgender individuals, using Noblit and Hare's meta-ethnography method. The Critical Appraisal Skills Programme was also used to appraise the 18 included studies.

Results: Data from the included 18 individual studies ranged from moderate to strong in quality. Data analysis revealed five major themes which influenced transgender individuals' daily lives. These were gender transition and disclosing gender identity, health and self-isolation, living with stigma and discrimination: health care, leisure and work, the importance of relationships, and last, overcoming adversity: stories of what can work.

Conclusion: This meta-synthesis reinforces many preconceived notions about transgender individuals. These include being at high risk of social exclusion, experiencing discrimination and stigma across many social situations, and last, being at high risk of poor wellbeing. This study also found that there is further need for studies that investigate the self-isolation of transgender individuals as well as this group's relationship and experiences with health care professionals and providers.     

Transgender and anxiety: A comparative study between transgender people and the general population

Background: Anxiety disorders pose serious public health problems. The data available on anxiety disorders in the transgender population is limited by the small numbers, the lack of a matched controlled population and the selection of a nonhomogenous group of transgender people.

Aims: The aims of the study were (1) to determine anxiety symptomatology (based on the HADS) in a nontreated transgender population and to compare it to a general population sample matched by age and gender; (2) to investigate the predictive role of specific variables, including experienced gender, self-esteem, victimization, social support, interpersonal functioning, and cross-sex hormone use regarding levels of anxiety symptomatology; and (3) to investigate differences in anxiety symptomatology between transgender people on cross-sex hormone treatment and not on hormone treatment.

Methods: A total of 913 individuals who self-identified as transgender attending a transgender health service during a 3-year period agreed to participate. For the first aim of the study, 592 transgender people not on treatment were matched by age and gender, with 3,816 people from the general population. For the second and third aim, the whole transgender population was included.

Measurements: Sociodemographic variables and measures of depression and anxiety (HADS), self-esteem (RSE), victimization (ETS), social support (MSPSS), and interpersonal functioning (IIP-32).

Results: Compared with the general population transgender people had a nearly threefold increased risk of probable anxiety disorder (all p < .05). Low self-esteem and interpersonal functioning were found to be significant predictors of anxiety symptoms. Trans women on treatment with cross-sex hormones were found to have lower levels of anxiety disorder symptomatology.

Conclusions: Transgender people (particularly trans males) have higher levels of anxiety symptoms suggestive of possible anxiety disorders compared to the general population. The findings that self-esteem, interpersonal functioning, and hormone treatment are associated with lower levels of anxiety symptoms indicate the need for clinical interventions targeting self-esteem and interpersonal difficulties and highlight the importance of quick access to transgender health services.     

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.     

Mental health practitioners' attitudes towards transgender people: A systematic review of the literature

Background: A systematic review was conducted to critically evaluate and synthesize literature investigating mental health practitioners' attitudes towards transgender people.

Objective: Three primary objectives were outlined; first, establish whether overall attitudes are positive or negative. Second, explore whether training, education or experience influences attitudes and finally, examine participant demographics in relation to attitude trends.

Method: A systematic electronic search was carried out in March 2017 using Medline, PsycINFO, PsycArticles, CINAHL, ASSIA, and Web of Science electronic databases. Manual citation and ancestral searches were conducted on identified papers. Qualitative, quantitative and mixed method studies were eligible for inclusion. A total of 13 papers of mixed quality were identified.

Results: Existing literature is limited to cross-sectional, quantitative data and fails to investigate differences between implicit and explicit attitudes. Small to moderate convenience samples reduce the generalizability of data. Overall attitudes were positive although negative attitudes were more frequent in male, Caucasian, heterosexual, religious, conservative mental health professionals.

Conclusions: Refined scales are needed to address the unique heterogeneity within transgender populations. Future research should focus on how attitudes impact care provided and employ longitudinal designs to explore the sustainability of targeted attitudinal training.     

Barriers and facilitators of physical activity and sport participation among young transgender adults who are medically transitioning

Background: Transgender people (those who feel incongruence between the gender they were assigned at birth and their gender identity) engage in lower levels of physical activity compared to cisgender (non-transgender) people. Several factors have been shown to affect physical activity engagement in the cisgender population; however, the physical activity experiences of young transgender adults have not been explored. It is therefore the aim of the current study to understand what factors are associated with physical activity and sport engagement in young transgender adults who are medically transitioning.

Method: Semi-structured interviews were conducted with 14 young transgender adults (18–36 years) who had initiated their medical transition at a transgender health service in the United Kingdom. The data were analyzed using thematic analysis.

Results: Two main themes were identified: (1) barriers and (2) facilitators to physical activity and sport. Overall, the young transgender adults were insufficiently active due to inadequate changing facilities, body dissatisfaction, fears surrounding “passing” and not being accepted by others. At the same time, participants were motivated to engage in physical activity to increase their body satisfaction and gender congruence. However, participants felt there was a lack of safe and comfortable spaces to engage in physical activity and sport.

Conclusion: Young transgender adults who are medically transitioning experience several barriers to physical activity and sport, despite being motivated to be physically active. Initiatives to facilitate young transgender adults' ability to put their motivations into practice (i.e. to be more physically active) are needed.     

Effectiveness of testosterone therapy for masculinizing voice in transgender patients: A meta-analytic review

Background: Testosterone therapy is the predominant treatment for voice masculinization in transgender patients. Although lowering of voice fundamental frequency (f₀) occurs with testosterone therapy, evidence suggests voice and gender identity may not fully align—i.e., voice-gender congruence may not be achieved—with its use.

Aim: This meta-analytic review evaluates the effectiveness of testosterone therapy to masculinize voice in transgender patients.

Methods: Multiple electronic databases were queried (inclusion dates: from database inception up to October 27, 2017) to identify original research on voice masculinization using testosterone therapy. Nineteen articles were included in this meta-analytic review, which followed PRISMA guidelines. In addition to qualitative analyses, random effects proportion meta-analyses were performed on data related to f₀, voice-gender congruence, voice problems, and satisfaction with voice.

Results: A meta-analysis on f₀ data showed after 1 year of testosterone therapy a combined estimate of 21% of participants (95% confidence interval [CI]: 5%–43%; I²: 59.9%) did not achieve cisgender male normative frequencies (f₀ ≤ 131 Hz). Meta-analyses on incomplete voice-gender congruence and voice problems indicated combined estimates of 21% (95% CI: 10%–34%; I²: 0.0%) and 46% (95% CI: 14%–79%; I²: 90.2%), respectively. Regarding incomplete satisfaction with voice, a meta-analysis showed a combined estimate of 16% (95% CI: 7%–28%; I²: 0.0%).

Discussion: We found that not all transgender patients using testosterone therapy to masculinize voice should expect f₀ lowering to cisgender male normative frequencies after 1 year. The vocal transition may involve voice problems for many patients, and some might not achieve voice-gender congruence without additional, voice-specific intervention. Given these findings, a voice evaluation should occur prior to initiating testosterone therapy and involve counseling on expectations for voice. Transgender patients who pursue voice masculinization may need management from laryngology and speech and language therapy to improve voice-gender congruence, mitigate voice problems, and increase satisfaction with voice.     

Changes over time in head and neck cancer patients’ and caregivers’ illness perceptions and relationships with quality of life

Objective: This study investigated changes in illness perceptions from diagnosis to six months later in patients with head and neck cancer (HNC) and their caregivers. The study also examined whether discrepancy in patient and caregiver perceptions at diagnosis predicted patient health-related quality of life (HRQL) at six months.

Design: Forty-two patient–caregiver dyads completed the Brief Illness Perception Questionnaire (Brief IPQ) at diagnosis and again six months later. Patients also completed a HRQL questionnaire at both time points. Analyses were performed using the Actor–Partner Interdependence Model.

Main Outcome Measure: Total patient HRQL assessed by the Functional Assessment of Cancer Therapy (FACT-H&N).

Results: Perceptions of emotional impact and illness concern reduced over time in patients and caregivers. Perceptions of treatment control and identity increased in caregivers only. After controlling for the effects of baseline HRQL, and the individual contribution of patient and caregiver illness perceptions, greater discrepancy in perceptions of timeline, personal control, and illness identity among dyads at diagnosis predicted lower patient HRQL at six-month follow-up.

Conclusion: Patients’ and their caregivers’ perceptions of HNC are dynamic over time. Greater discrepancy between patients’ and caregivers’ illness perceptions at diagnosis predict poorer subsequent patient HRQL.     

Coping with transphobia in employment: Strategies used by transgender and gender-diverse people in the United States

Background: Transgender and gender-diverse (TGD) individuals face stigma in the general public and in the workplace. Research has suggested that TGD individuals may demonstrate unique coping strategies in the workplace in order to manage transphobia in that setting; however, further research is needed to identify the specific strategies that transgender individuals use to deal with transphobia at work.

Method: The present qualitative study utilized the grounded theory methodology to identify the specific coping strategies utilized to deal with transphobia at work. Participants included 45 TGD participants from the northeastern United States.

Results: The results of the study include the identification of eight coping-strategy themes including gender-presentation strategies, gender detachment, relationship navigating, resource utilization, job-performance strategies, maladaptive coping strategies, structural strategies, and power-acquisition strategies.

Conclusions: Implications of the present study suggest the resilience and diverse coping strategies that mental health providers can help TGD workers draw from in dealing with transphobia at work. In addition, there is a need for greater remediation and prevention of employment-related transphobia, including leadership within employment settings, greater legal protections, and enforcement of these laws in the United States.     

Internalized transphobia: Exploring perceptions of social messages in transgender and gender-nonconforming adults

Background: Transgender and gender nonconforming (TGNC) individuals encounter a variety of minority stressors that have yet to be fully articulated or explored within the research literature. The purpose of this study is to better understand internalized stigma—the experience of accepting and internalizing negative social messages and experiences about one's identity—an underexplored minority stressor for TGNC people.

Method: We conducted in-depth interviews with 30 diverse TGNC participants using consensual qualitative research (CQR) methodology.

Results: Following data saturation and analysis, six distinct themes emerged across participants: (1) TGNC identities are regarded negatively by society; (2) social messages are perceived as originating from the media and religious ideology; (3) TGNC individuals report emotional distress; (4) negative self-perceptions in response to social messages; (5) TGNC individuals report resilience processes in response to negative social messages; and (6) social messages are perceived generally to differentially impact TGNC people of color.

Conclusion: Findings highlight the common experience of encountering social marginalization for TGNC individuals. Structural interventions that target pervasive sociocultural messages regarding TGNC identities are warranted.     

Physical and mental health trajectories of cancer patients and caregivers across the year post-diagnosis: a dyadic investigation

Objective: Evidence suggests interdependence between cancer patients’ and their caregivers’ physical and mental health. However, the extent to which caregivers’ health relates to their patients’ recovery, or patients’ health affects their caregivers’ outcomes, is largely unknown. This dyadic investigation reports the relations between cancer patients’ and their caregivers’ physical and mental health trajectories during the year following diagnosis.

Design: Ninety-two colorectal cancer patient–caregiver dyads completed questionnaires at 2, 6 and 12 months post-diagnosis.

Outcome measures: Self-reported physical and mental health using the Medical Outcomes Study Short Form Health Survey-12.

Results: Patients reported improved physical health over the year following their diagnosis, whereas caregivers reported declining physical health. Patients with lower mental health at diagnosis had stagnated physical health recovery. Caregivers’ physical health declined most noticeably among those reporting low mental health at diagnosis and whose patients reported low physical health at diagnosis.

Conclusion: Findings suggest targeting health interventions to cancer patients and caregivers reporting poor mental health at diagnosis may mitigate their long-term physical morbidity. Limited evidence of dyadic interdependence between patients’ and caregivers’ physical and mental health trajectories suggests future studies are warranted to identify psychosocial and medical characteristics moderating the relations between patients’ and caregivers’ health.     

Estimating the population size of transgender women in San Francisco using multiple methods, 2013

Purpose: To estimate the number of adult transgender women (TGW) in San Francisco and to provide an example of how estimation can be conducted.

Methods: Using nine different services accessed by the TGW population, the service multiplier, integrated into a respondent-driven sampling (RDS) survey of TGW, was used to calculate nine estimates of the TGW population in San Francisco. Both the successive sampling method, also integrated into the RDS survey of TGW, and a population proportion from the literature each calculated an additional estimate of the TGW population. The median of all 11 estimates was calculated to present a single estimate of the TGW population in San Francisco.

Results: The median of estimates was 978 TGW in San Francisco (plausibility bounds 635 – 1,400). This estimate is consistent with known cases of HIV among TGW and surveys on the prevalence of infection in the TGW population.

Conclusion: Using multiple methods, we estimate the TGW population size to be 0.13% of the San Francisco population. Despite small numbers, TGW bear a disproportionate burden of HIV infection in San Francisco. TGW are a priority for HIV care and prevention services.     

Managing multiple chronic conditions in Singapore – Exploring the perspectives and experiences of family caregivers of patients with diabetes and end stage renal disease on haemodialysis

Objective: Diabetes mellitus (DM) is the commonest cause of end stage renal disease (ESRD). Despite increasing DM-ESRD prevalence and high dependency on care, there is a lack of literature on DM-ESRD caregivers. We sought to explore the perspectives and experiences of caregivers of patients with DM undergoing haemodialysis in Singapore.

Design: This study employed an exploratory, qualitative design comprising in-depth interviews with caregivers of DM-ESRD patients.

Methods: Semi-structured interviews were conducted with a sample of 20 family caregivers (54.2 ± 12.6 years; 75% female) of DM-ESRD patients. Data were analysed using Thematic Analysis.

Results: Key caregiving challenges identified were managing diet, care recipients’ emotions and mobility dependence. Patients’ emotional reactions caused interpersonal conflicts and hindered treatment management. Difficulties in dietary management were linked to patients’ erratic appetite, caregivers’ lack/poor understanding of the dietary guidelines and caregivers’ low perceived competence. Limited resources in terms of social support and finances were also noted. Physical and psychological well-being and employment were adversely affected by caregiving role.

Conclusion: This study highlights distinctive aspects of the DM-ESRD caregiving experience, which impact on caregivers’ health and challenge care. Disease management programmes should be expanded to support caregivers in dealing with multimorbidity.     

Combined hysterectomy and mastectomy surgery for transgender patients in an integrated health care setting

Background: Hysterectomy and mastectomy surgery for gender affirmation have traditionally been performed as separate surgeries. Our institution offers these surgeries as a single combined procedure, typically with same-day discharge. Decreasing the number of times patients need to have surgery may reduce barriers to care by limiting surgical and hospital stay events. Our primary objective was to describe the perioperative experience of transgender patients who underwent combined hysterectomy and mastectomy surgery.

Methods: This retrospective case series assessed patients who underwent combined hysterectomy and mastectomy surgery between 2013 and 2015 in an integrated health care setting in the United States. Chart reviews were performed for outcomes of interest, which included operative and postoperative complications.

Results: We identified 25 patients who underwent a combined hysterectomy and mastectomy for the indication of gender transition. Preoperative patient characteristics included a median age of 31, with a median BMI of 25. Ninety-two percent of the patients were on testosterone therapy at the time of surgery. A total of 76% and 24% of patients had laparoscopic and vaginal hysterectomies, respectively. Intraoperatively, the average blood loss was 104 mL, and there were no complications. Eighty percent of patients were discharged on the same day. Postoperatively, 92% of patients experienced no major complications. One patient received a uterine artery embolization and blood transfusion for postoperative intraabdominal bleeding, and one patient presented 9 weeks after surgery with partial vaginal cuff dehiscence requiring a cuff revision. There were no re-admissions within six months of surgery. There were no major mastectomy-related complications.

Conclusions: Combined surgeries are feasible and reduce the number of surgical events and hospital stays. There were no complications that could be attributed to undergoing two procedures as a single incident.     

Investigating the outcome of the initial assessment at a national transgender health service: Time to review the process?

Background: Globally, there is a lack of a standardized assessment process prior to the initiation of gender affirming medical interventions and consequently there is a discrepancy in this process among different transgender health services.

Aim: The main objective of this study is to investigate the outcome of the initial assessment process at a national transgender health service.

Method: The outcome of people over the age of 17 years, assessed at a large national transgender health service in the United Kingdom during a 2-year period was categorized into: (1) recommendation for cross-sex hormone treatment, or (2) no recommendation for cross-sex hormone treatment. In addition, 200 case notes were reviewed in order to investigate the level of agreement between the two clinicians involved in the assessment process.

Results: During the study period, a total number of 617 people completed their assessment at the service. Following assessment 380 (61.6%) patients were recommended for cross-sex hormone treatment, leaving 237 (38.4%) patients who required a longer assessment period or were discharged. The factors associated with being recommended for cross-sex hormone treatment were having socially transitioned, not smoking, having initiated cross-sex hormones prior to assessment, being older, and assigned male at birth. Out of the 200 case notes reviewed, agreement between assessor 1 and 2 (3 months apart) was found in 88% (n = 176) of the cases.

Discussion: Although the results of the study may not be generalizable to other international centers, questioning the assessment process and the role of the assessors is important to ensure treatment is offered in a timely and efficient manner. The findings from this study suggest that the routine inclusion of two assessors needs to be reviewed.     

Relationship among gender-related stress,resilience factors,and mental health in a Midwestern U.S. transgender and gender-nonconforming population

Background: Transgender and gender-nonconforming individuals experience more discrimination than their cisgender peers, and this discrimination can be associated with poorer mental health. This study used the gender minority stress model as a framework to examine the relationship among gender-related stressors and resilience factors and mental health outcomes. The study particularly aimed to increase knowledge of the gender-nonconforming population.

Methods: A community sample of 83 individuals that identify as a gender different than the sex assigned to them at birth completed an online survey. Depression and anxiety were assessed using the Center for Epidemiological Studies Depression Scale (CES-D) and Beck Anxiety Inventory (BAI), respectively. The Gender Minority Stress and Resilience measure was used to assess distal and proximal stressors and resilience factors.

Results: The median CES-D and BAI scores were 16 and 13, respectively. Forty percent had a history of non-suicidal self-injury (NSSI), 75% had experienced suicidal ideation, and 45% had attempted suicide. Proximal stress was found to be a positive predictor of depressive symptoms. Resilience was a weak negative predictor of anxiety symptoms. Distal stress was a positive predictor of suicide attempts, and resilience factors and hormone use were marginal negative predictors of suicide attempt. Trans women were significantly less likely to have engaged in NSSI, but had a significantly higher proximal stress score than trans men and gender-nonconforming individuals.

Conclusion: Our study found high rates of mental health problems in the trans and gender-nonconforming sample. Our findings in part support the gender minority stress model, with gender-related stress predicting certain mental health problems and resilience being a negative predictor. Overall, gender-nonconforming individuals have had similar experiences and mental health findings as transgender individuals.