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Research into access to and experiences with healthcare services of gender-diverse and trans individuals remains scarce. In this paper, self-reported experiences with general and trans-specific healthcare services were analyzed for differences between gender-diverse people, trans men, and trans women, using data from a five-country survey. More than half of all respondents indicated they had delayed general healthcare services at least once because of their gender identity, mostly out of fear of being treated badly. Almost one in four participants felt personally discriminated against in general healthcare services within the previous year. Gender-diverse people had significantly less experiences with seeking trans-specific healthcare. Additional effects were found for different socio-demographic variables (age; sex assigned at birth; educational level; socioeconomic status; and belonging to an ethnic, sexual, and/or disability minority). Gender-diverse people gave significantly worse evaluations of trans-specific healthcare services (in general as well as for specific types of trans-specific healthcare). The findings highlight the need for healthcare providers in creating inclusive healthcare settings, with attention for gender-diverse clients and those belonging to precarious minority groups due to their level of education or sexual, disability, and/or ethnic background.

Research on gender variant children and adolescents has stirred debate on the increased amount of referrals, the sex ratio in referrals, the impact of trans care on their psychological well-being, and the amount of children/adolescents who stop treatment. This retrospective study includes the number of referrals, first contacts at the outpatient clinic and the amount of drop-outs between January 1st 2007 to December 31st 2016 from the sole Belgian Pediatric Gender clinic. Emotional and behavioral problems, measured by the Child Behavioral Checklist (CBCL) and the Youth Self-Report (YSR), were screened. The adolescents who ceased the counseling, were contacted for follow-up. We included 235 adolescents, referred to the clinic, and 177 (of 235) who had a first physical appointment with a psychologist. Almost one in four (24.5%) on the YSR and more than half (54.8%) on the CBCL fall within the clinical range on the total problem score. On the YSR, 40.4% reported having suicide thoughts and 32.1% reported self-harm behavior and/or at least one suicide attempt, all in the last six months. Five adolescents committed suicide. According to parents, more difficulties with peers predicts more emotional and behavioral problems (F(5, 36) = 3.539, p = 0.011). In this study group, 29 adolescents ceased the counseling, whereof 7 could be traced back in the adult gender clinic after 2016. Results are indicative of the need for mental support for trans youth and their families and moreover, highlight the need for longitudinal follow-up studies.

Return to work (RTW) or work resumption after a work absence due to psychosocial or medical reasons benefits the well-being of a person, including transgender people, and is nowadays a major research domain. The objective is to examine, through an occupational lens, the literature reporting objective RTW outcomes and experiences in transgender people to (a) synthesize what is known about return to work (full-time, part-time, or self-employed) and (b) describe which gaps persist. Several databases and the gray literature were explored systematically. Studies between November 1, 2006 and March 1, 2021 revealing RTW quantitative and qualitative data of adult transgender people were eligible. This review was registered on PROSPERO (CRD42019128395) on April 30, 2019. Among the 14,592 articles initially identified, 97 fulfilled the inclusion criteria which resulted in 20 being analyzed. Objective RTW outcomes, such as number of RTW attempts, time to RTW or number of sick days, were lacking; thus, other relevant work outcomes were reported. Compared to the general population, lower employment rates and more economic distress were observed, with trans women in particular saying that their work situation had deteriorated. Research on positive RTW experiences was highlighted by the importance of disclosure, the support from especially managers and coworkers who acted as mediators, personal coping, and a transition plan along with work accommodations. Negative work experiences, such as demotion, lay-offs, and discrimination were often prominent together with a lack of knowledge of trans issues among all stakeholders, including occupational health professionals. Few studies have explored employment characteristics and experiences of transgender people (TP). RTW is a dynamic process along with transition in itself, which should be tailored through supportive policies, education, a transition plan and work accommodations with the help of external experts. Future studies should include more occupational information and report RTW outcomes to enhance our knowledge about the guidance of TP and to make way for interventional studies.

ObjectivesThis study aimed to explore the role of occupational physicians (OPs) in supporting transgender and gender-diverse (TGD) workers during gender transition and return to work (RTW) following gender-affirming (medical) interventions.DesignWe conducted a qualitative study (ONZ-2023-0026) using focus groups.SettingThis study involved OPs in Belgium.ParticipantsTwo semistructured focus group interviews were held with 19 OPs working in occupational health services in Belgium in May and November 2023. Purposeful sampling was used, which included OPs with at least 2 years of seniority and experience with TGD people or inclusive company culture. Participants were predominantly white and cisgender, with varying levels of seniority and sectoral coverage.MethodsQualitative data was thematically analysed using Braun and Clarke to find patterned meaning.ResultsThe analysis created four themes: (1) ‘What is the right professional attitude?: You never get a second chance to make a good first impression’ discusses the aspects of professional attitude alongside ethical considerations; (2) ‘Controlled open-mindedness’ entails values and views of gender in light of medicine, the individual worker, organisations and society; (3) ‘The balance game: “Fingerspitzengefühl” (intuitive flair or instinct) without treating’ and (4) ‘Being gender-bombarded: the need for OP-tailored training and best practices’. These themes highlighted the limited knowledge and experience of OPs regarding gender-affirming care (GAC) and their need for additional training. Participants struggled to find the best gender-inclusive professional approach to support TGD workers as well as employers and require ‘best practices’. Implementing overarching legislative frameworks can help OPs and companies create an inclusive work environment considering the differences in occupational sectors and company culture. RTW policies should focus on abilities without medicalisation and stigmatisation and involve multiple stakeholders.ConclusionsOccupational medicine can be crucial in improving the health and well-being of TGD workers. However, with the ageing workforce, gender diversity poses new ‘hidden’ challenges for sick leave management, RTW and sensitive health surveillance. Multidisciplinary training with stakeholders and GAC professionals can enhance occupational practice and equip future OPs with the necessary competencies and confidence.

Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW’s health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.

HIV prevalence and sexual risk have been estimated very high for transgender people. However, the limited sampling and data collection methods used in current research on transgender people potentially led to overrepresentation and generalisation of people at risk for HIV. Current HIV prevalence estimates in transgender populations are generalised from studies mainly focusing on transgender women engaging in sex work. Moreover, studies focusing on non-binary people, who identify with a broad range of identities beyond the traditional male and female gender identities, are scarce. To estimate the HIV prevalence rate in the Flemish and Brussels (Belgium) transgender population, including transgender women, transgender men and non-binary people, and to identify the associated risk factors. In this community-based cross-sectional study, self-identified transgender and non-binary (TGNB) people will be recruited through a two-stage time-location sampling approach. First, community settings in which TGNB people gather will be mapped to develop an accurate sampling frame. Secondly, a multistage sampling design is applied involving a stratification based on setting type (healthcare facilities vs outreach events), a selection of clusters by systematic sampling and a simple random selection of TGNB people within each cluster. Participants will complete an electronic self-reported survey to measure sociological, sexual and drug-using behaviors (risk factors) and oral fluid aliquots will be collected and tested for HIV antibodies. Logistic regression models will be used to evaluate risk factors independently associated with HIV infection. The presented study is registered at ClinicalTrials.gov (NCT04930614). This study will be the first to investigate the HIV prevalence rates and associated risk behaviors in an accurate representation of the TGNB population in a Western European country. The findings will globally serve as a knowledge base for identifying subgroups at risk for becoming infected with HIV within TGNB people and to set up targeted prevention programs.

Background Previous studies report vast mental health problems in sexual minority people. Representative national proportion estimates on self-identifying LGB+ persons are missing in Belgium. Lacking data collection regarding sexual orientation in either census or governmental survey data limits our understanding of the true population sizes of different sexual orientation groups and their respective health outcomes. This study assessed the proportion of LGB+ and heterosexual persons in Belgium, LGB+ persons’ self-identification as sexual minority, mental health, and experienced minority stress. Method A representative sample of 4632 individuals drawn from the Belgian National Register completed measures of sexual orientation, subjective minority status, and its importance for their identity as well as a range of mental-health measures. Results LGB+ participants made up 10.02% of the total sample and 52.59% of LGB+ participants self-identified as sexual minority. Most sexual minority participants considered sexual minority characteristics important for their identity. LGB+ persons reported significantly worse mental health than heterosexual persons. Sexual minority participants did not report high levels of minority stress, but those who considered minority characteristics key for their identity reported higher levels of minority stress. LGB+ participants who did not identify as minority reported fewer persons they trust. Conclusions The proportion of persons who identified as LGB+ was twice as large as the proportion of persons who identified as a minority based on their sexual orientation. LGB+ persons show poorer mental health compared to heterosexual persons. This difference was unrelated to minority stress, sociodemographic differences, minority identification, or the importance attached to minority characteristics.

In this article we reflect upon the evolution from the Belgian trans law of 2007 to those of 2017 and beyond, giving adult citizens the possibility to have their self-determined gender legally recognised. The 2019 ruling of the Belgian Constitutional Court, condemning the Belgian State for being discriminatory against gender fluid and gender non-binary persons regarding their legal gender recognition, requires the Belgian government to either add a third legal option or to abolish gender registration altogether. We analyse the definitions of sex and gender that underlie the two trans laws of 2007 and 2017 and the Constitutional Court ruling of 2019 and then confront them with the experiences of trans people based on a national transgender survey (Motmans, Wyverkens, & Defreyne, 2017). The confrontation between legal texts and lived experiences clearly shows the promises and pitfalls states face when striving for gender recognition procedures.

Background/Objectives: Persons identifying as lesbian, gay, bisexual, pansexual, omnisexual, queer, questioning, fluid, asexual, or other non-heterosexual orientations (LGB+ persons) have been identified as a risk group for sexual victimization (SV), which can have long-lasting negative effects on well-being and physical, mental, sexual, and reproductive health. Othering-Based Stress (OBS)—reflecting societal processes of othering and resulting from stigma, prejudice, and discrimination—may contribute to increased vulnerability to SV and its consequences in LGB+ persons and affect help-seeking behavior following victimization. This study examines the impact of SV on LGB+ persons and their help-seeking behavior after victimization. Methods: Using a mixed-methods explanatory sequential design, first survey data from a nationally representative sample of the Belgian population on SV, its consequences, and subsequent help-seeking behavior were collected from 4632 individuals. Of these, 2965 participants (2601 heterosexual and 364 LGB+ individuals) experienced SV and represented the final sample for the quantitative analyses. In a second phase, in-depth interviews were conducted with 40 LGB+ victims to explore their experiences more thoroughly. Results: LGB+ individuals reported more negative consequences following SV than heterosexual persons, particularly regarding identity-related processes such as questioning gender expression and decreases in self-esteem. They also reported additional barriers to disclosing SV and seeking help from professional services or the police, including fears of stigma, invalidation, and concerns about professionals’ LGB+ competence. No significant differences were found between LGB+ persons who explicitly identified as belonging to a sexual minority group and those who did not, neither in the perceived consequences of SV nor in help-seeking barriers. Conclusions: LGB+ victims of sexual violence experienced more severe identity-related consequences and faced greater barriers to professional support than heterosexual victims. These results highlight the urgent need for trauma-informed, LGB+-inclusive services and structural policy measures to improve access to appropriate care.

All healthcare professionals will find themselves supporting care for a transgender or gender diverse person at some point, and education and research need to be widened, write Guy T’Sjoen and Joz Motmans