Dataset Information

Understanding community member and health care professional perspectives on gender-affirming care-A qualitative study.

ABSTRACT:

Background

Transgender and gender diverse (TGD) people experience significant barriers to accessing affirming health services. There is a paucity of literature examining how both community members and health care professionals (HCPs) understand potential causes and solutions for these barriers, particularly in non-urban settings.

Objective

We present the first systematic examination of perspectives from community members and HCPs regarding barriers to and solutions for promoting access to gender-affirming health care.

Design

Study activities were conducted through the Plan and Act for Transgender Health (PATH) Project, a health needs assessment of TGD people. Community members in the catchment area were recruited to participate in focus group discussions about access to gender-affirming health care and optimal health service delivery models in March-October 2019. HCPs were recruited to participate in focus group discussions or in-depth interviews about experiences working with TGD clients. Data were analyzed using an inductive grounded theory approach.

Setting

25 rural counties in Massachusetts, New York, Connecticut, Vermont, and New Hampshire.

Participants

Study participants included 61 adult TGD community members and 23 HCPs working in the catchment area.

Results

Both community members and HCPs spoke of the need for connectedness and linkages among disparate health system components for gender-affirming health care. Participants expressed this priority through calls for systems-level improvements within existing services (e.g., expanded data collection, expanded mental health services, inclusive and affirming health care environments, and TGD staff). They also expressed the need for expanded TGD community outreach and engagement (e.g., incorporation of a patient feedback process, TGD health navigators, and resource mapping).

Limitations

Findings specifically reflect the perspectives of community members and HCPs in the rural New England area. Furthermore, the study sample was predominantly White non-Hispanic.

Conclusion

Interventions to achieve accessible gender-affirming health care must address the diverse perspectives and needs of both community members and HCPs.

SUBMITTER: Loo S

PROVIDER: S-EPMC8366980 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ObjectiveGender-affirming hormones (GAH)-the use of sex hormones to induce desired secondary sex characteristics in transgender individuals-is vital healthcare for many transgender people. Among prescribers of GAH, there is debate regarding the value of a universal requirement for an evaluation by a mental health provider prior to GAH initiation. The purpose of this qualitative study was to describe the range of attitudes and approaches to mental health evaluation among GAH providers in the United States. We analyzed the providers' attitudes and base our recommendations on this analysis.MethodsWe conducted semi-structured interviews with 18 healthcare providers who prescribe GAH across the United States. Participants were purposefully recruited using professional networks and snowball sampling to include those who require mental health evaluation and those who do not. We adapted domains from the Theoretical Domains Framework-a framework for understanding influences on health professional behavior-to inform the interviews and analysis. Guided by these domains, we iteratively coded text and identified theoretical relationships among the categories.ResultsWhile some felt a universal requirement for mental health "clearance" was necessary for the identification of appropriate candidates for GAH, others described this requirement as a form of "gatekeeping" that limits access to care. Themes we identified included providers' ability to ascertain gender identity; concern about mental illness; GAH provider and mental health provider expertise; and provider roles. All providers appreciated the potential advantages of mental health support during GAH treatment.ConclusionProviders in our study practice on a continuum of care rather than adhering to strict rules about the requirement for mental health evaluation prior to GAH treatment. Where they fall on this continuum is influenced primarily by their perceptions of transgender identity and transition, and their interpretation of risk for significant mental illness and its association with transness. Providers who required universal evaluation by a mental health professional tended to hold essentialist, medicalized, and binary ideas of gender and transness.

Project description:BACKGROUND:Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse people have experienced significant marginalization and discrimination in health care settings. Health professionals are generally not adequately prepared by current curricula to provide appropriate healthcare to trans and gender diverse people. This strongly implies that health care students would benefit from curricula which facilitate learning about gender-affirming health care. MAIN BODY:Trans and gender diverse people have been pathologized by the medical profession, through classifications of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). Although this is changing in the new ICD-11, tension remains between depathologization discourses and access to gender-affirming health care. Trans and gender diverse people experience significant health disparities and an increased burden of disease, specifically in the areas of mental health, Human Immunodeficiency Virus, violence and victimisation. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professional ignorance. This paper will outline gaps in health science curricula that have been described in different contexts, and specific educational interventions that have attempted to improve awareness, knowledge and skills related to gender-affirming health care. The education of primary care providers is critical, as in much of the world, specialist services for gender-affirming health care are not widely available. The ethics of the gatekeeping model, where service providers decide who can access care, will be discussed and contrasted with the informed-consent model that ?upholds autonomy by empowering patients to make their own health care decisions. CONCLUSION:There is an ethical imperative for health professionals to reduce health care disparities of trans and gender diverse people and practice within the health care values of social justice and cultural humility. As health science educators, we have an ethical duty to include gender-affirming health in health science curricula in order to prevent harm to the trans and gender diverse patients that our students will provide care for in the future.

Project description:ImportanceMedical education, research, and clinical guidelines are available to support the initiation of gender-affirming care for transgender and nonbinary people. By contrast, little is known about the clinical experiences of those who discontinue or seek to reverse gender-affirming medical or surgical interventions due to a change in gender identity, often referred to as detransition.ObjectiveTo examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice.Design, setting, and participantsUsing constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants' social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed.Main outcomes and measuresIn-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions.ResultsAmong the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.Conclusions and relevanceThis study's results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.

Project description:ImportanceTransgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care.ObjectiveTo investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality.Design, setting, and participantsThis prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021.ExposuresTime since enrollment and receipt of PBs or GAHs.Main outcomes and measuresMental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome.ResultsAmong 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded "I don't know" or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51).Conclusions and relevanceThis study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.

Project description:RATIONALE:While breastfeeding is well recognized as beneficial, rates of breastfeeding among American Indian women are below average and contribute to health inequities. Culturally specific approaches to breastfeeding research are called for to inform appropriate interventions in American Indian communities. Specifically, a grandmother's role in breastfeeding promotion is of great import particularly in American Indian (AI) groups, although is an understudied topic to date. OBJECTIVE:This research seeks to fill a prominent literature gap by utilizing a grounded theory and community-based research approach to inform breastfeeding practices from the voices of grandmothers and health care professionals in a rural AI community in the United States. METHODS:A community-based approach guided the research process. Convenience and snowball sampling was used to recruit for semi-structured and follow up member checking interviews with AI grandmothers (n?=?27) and health care professionals (n?=?7). Qualitative data were transcribed, characterized into meaning units, and coded by a review panel. Data were reconciled for discrepancies among reviewers, organized thematically, and used to generate community-specific breastfeeding constructs. RESULTS:Three major themes emerged, each with relevant subthemes: (1) importance of breastfeeding; (2) attachment, bonding, and passing on knowledge; and (3) overburdened health care system. Multiple subthemes represent stressors and impact breastfeeding knowledge, translation, and practice within this community including formula beliefs, historical traumas, societal pressures, mistrust, and substance abuse. CONCLUSIONS:Interventions designed to raise breastfeeding rates in the study site community would ideally be grounded in tribal resources and involve a collaborative approach that engages the greater community, grandmothers, health care professionals, and scientific partners with varying skills. More research is needed to determine stressors and any potential impact on infant feeding practices among other AI groups. Application of the research approach presented here to other AI communities may be beneficial for understanding opportunities and challenges to breastfeeding practices.

Project description:Background Trauma-informed (TI) approach is a framework for a system change intervention that transforms the organizational culture and practices to address the high prevalence and impact of trauma on patients and healthcare professionals, and prevents re-traumatization in healthcare services. Review of TI approaches in primary and community mental healthcare identified limited evidence for its effectiveness in the UK, however it is endorsed in various policies. This study aimed to investigate the UK-specific context through exploring how TI approaches are represented in health policies, and how they are understood and implemented by policy makers and healthcare professionals. Methods A qualitative study comprising of a document analysis of UK health policies followed by semi-structured interviews with key informants with direct experience of developing and implementing TI approaches. We used the Ready Extract Analyse Distil (READ) approach to guide policy document review, and the framework method to analyse data. Results We analysed 24 documents and interviewed 11 professionals from healthcare organizations and local authorities. TI approach was included in national, regional and local policies, however, there was no UK- or NHS-wide strategy or legislation, nor funding commitment. Although documents and interviews provided differing interpretations of TI care, they were aligned in describing the integration of TI principles at the system level, contextual tailoring to each organization, and addressing varied challenges within health systems. TI care in the UK has had piecemeal implementation, with a nation-wide strategy and leadership visible in Scotland and Wales and more disjointed implementation in England. Professionals wanted enhanced coordination between organizations and regions. We identified factors affecting implementation of TI approaches at the level of organization (leadership, service user involvement, organizational culture, resource allocation, competing priorities) and wider context (government support, funding). Professionals had conflicting views on the future of TI approaches, however all agreed that government backing is essential for implementing policies into practice. Conclusions A coordinated, more centralized strategy and provision for TI healthcare, increased funding for evaluation, and education through professional networks about evidence-based TI health systems can contribute towards evidence-informed policies and implementation of TI approaches in the UK. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08461-w.

Project description:BackgroundThe concept of "intersectionality" is increasingly employed within public health arenas, particularly in North America, and is often heralded as offering great potential to advance health inequalities research and action. Given persistently poor progress towards tackling health inequalities, and recent calls to reframe this agenda in the United Kingdom and Europe, the possible contribution of intersectionality deserves attention. Yet, no existing research has examined professional stakeholder understandings and perspectives on applying intersectionality to this field.MethodsIn this paper we seek to address that gap, drawing upon a consultation survey and face-to-face workshop (n = 23) undertaken in the United Kingdom. The survey included both researchers (n = 53) and policy and practice professionals (n = 20) with varied roles and levels of engagement in research and evaluation. Topics included familiarity with the term and concept "intersectionality", relevance to health inequalities work, and issues shaping its uptake. Respondents were also asked to comment on two specific policy suggestions: intersectionally targeting and tailoring interventions, and evaluating the intersectional effects of policies. The workshop aims were to share examples of applying intersectionality within health inequalities research and practice; understand the views of research and practice colleagues on potential contributions and challenges; and identify potential ways to promote intersectional approaches.ResultsFindings indicated a generally positive response to the concept and a cautiously optimistic assessment that intersectional approaches could be valuable. However, opinions were mixed and various challenges were raised, especially around whether intersectionality research is necessarily critical and transformative and, accordingly, how it should be operationalized methodologically. Nonetheless, there was general agreement that intersectionality is concerned with diverse inequalities and the systems of power that shape them.ConclusionsWe position intersectionality within the wider context of health inequalities policy and practice, suggesting potential ways forward for the approach in the context of the United Kingdom. The views of policy and practice professionals suggest that intersectionality has far to travel to help counter individualistic narratives and to encourage an approach that is sensitive to subgroup inequalities and the processes that generate them. Examples of promising practice, albeit mostly in North America, suggest that it is possible for intersectionality to gain traction.