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Background Evidence suggests that transgender (trans) individuals in Canada are a medically underserved population; barriers range from lack of provider knowledge on trans issues to refusal of care. This paper provides the first formal estimation of health care inequalities between trans and cisgender individuals in Ontario, Canada. Methods Weighted statistics from the Ontario-wide Trans PULSE Project ( n  = 433) were compared with age-standardized Ontario data from the Canadian Community Health Survey ( n  = 39,980) to produce standardized prevalence differences (SPDs). Analysis was also conducted separately for trans men and trans women, each compared to the age-standardized Ontario population. Results An estimated 33.2% (26.4,40.9) of trans Ontarians reported a past-year unmet health care need in excess of the 10.7% expected based on the age-standardized Ontario population. Inequality was greatest comparing trans with cisgender men (SPD = 34.4% (23.0, 46.1). While trans Ontarians evaluated health care availability in Ontario similarly to the broader population, they were significantly more likely to evaluate availability in their community as fair or poor. Conclusions Trans Ontarians experience inequalities in perception and reported experiences of health care access, with 43.9% reporting a past-year unmet health care need.

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.

Background Members of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was to examine physician perceptions of barriers to healthcare provision for transgender patients. Methods This was a qualitative study with physician participants from Ontario, Canada. Semi-structured interviews were used to capture a progression of ideas related to barriers faced by physicians when caring for trans patients. Qualitative data were then transcribed verbatim and analysed with an emergent grounded theory approach. Results A total of thirteen (13) physician participants were interviewed. Analysis revealed healthcare barriers that grouped into five themes: Accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs. pathologising trans patients, and health system determinants. A centralising theme of “not knowing where to go or who to talk to” was also identified. Conclusions The findings of this study show that physicians perceive barriers to the care of trans patients, and that these barriers are multifactorial. Access barriers impede physicians when referring patients to specialists or searching for reliable treatment information. Clinical management of trans patients is complicated by a lack of knowledge, and by ethical considerations regarding treatments—which can be unfamiliar or challenging to physicians. The disciplinary division of responsibilities within medicine further complicates care; few practitioners identify trans healthcare as an interest area, and there is a tendency to overemphasise trans status in mental health evaluations. Failure to recognise and accommodate trans patients within sex-segregated healthcare systems leads to deficient health policy. The findings of this study suggest potential solutions to trans healthcare barriers at the informational level—with increased awareness of clinical guidelines and by including trans health issues in medical education—and at the institutional level, with support for both trans-focused and trans-friendly primary care models.

Background Transgender (TG) individuals experience discordance between their sex at birth and their gender identity. To better understand the health care needs and characteristics of TG youth that contribute to resilience, we conducted a qualitative study with clinical and non-clinical providers. Methods In-depth interviews were conducted of providers ( n  = 11) of TG youth (ages 13–21). Convenience and purposive sampling were used to recruit participants in the Boston area. All interviews were audio-recorded and transcribed verbatim. An interview guide of 14 open-ended questions was used to guide the discussion. A grounded theory approach was utilized to code and analyze the data, including double-coding to address issues of inter-rater reliability. Results Five primary themes emerged: 1) resilience of TG youth 2) lack of access to services that influence health, 3) the critical role of social support, 4) challenges in navigating the health care system, and 5) the need for trans-affirming competency training for providers and frontline staff. Conclusion The findings of this study show that providers recognize multiple barriers and challenges in the care of TG youth. However, they also identify the resilience exhibited by many youth. We propose that providers can further enhance the resilience of TG youth and help them flourish by offering them necessary resources via the creation of safe and welcoming clinical environments.

While the provision of gender affirming care for transgender people in South Africa is considered legal, ethical, and medically sound, and is-theoretically-available in both the South African private and public health sectors, access remains severely limited and unequal within the country. As there are no national policies or guidelines, little is known about how individual health care professionals providing gender affirming care make clinical decisions about eligibility and treatment options. Based on an initial policy review and service mapping, this study employed semi-structured interviews with a snowball sample of twelve health care providers, representing most providers currently providing gender affirming care in South Africa. Data were analysed thematically using NVivo, and are reported following COREQ guidelines. Our findings suggest that, whilst a small minority of health care providers offer gender affirming care, this is almost exclusively on their own initiative and is usually unsupported by wider structures and institutions. The ad hoc, discretionary nature of services means that access to care is dependent on whether a transgender person is fortunate enough to access a sympathetic and knowledgeable health care provider. Accordingly, national, state-sanctioned guidelines for gender affirming care are necessary to increase access, homogenise quality of care, and contribute to equitable provision of gender affirming care in the public and private health systems.

The World Professional Association for Transgender Health’s Standards of Care (WPATH SOC), now in its seventh edition, is a frequently cited, internationally recognized, evidence-based document that details a comprehensive framework for gender-related care of trans people. However, the WPATH SOC still relies heavily in some cases on gatekeeping practices, dubbed “triadic therapy,” or a process where a trans patient is encouraged to seek out psychotherapy, and hormone therapy, and only then be able to engage in surgical options for transitioning. I use G. Alan Marlatt’s harm reduction framework to argue that the triadic process creates its own set of harms that trans people have to contend with, especially insofar as it focuses on resolving gender dysphoria in a demanding, moralizing, and top-down way as opposed to enriching trans lives by reducing harms that prevent us from flourishing. Using Marlatt’s criterion that harm reduction ought to be bottom-up, low threshold, and not moralizing, I develop a list of suggestions for what ought to be centrally considered in treating trans patients.

When reached for comment, the USbased National Center for Transgender Equality referred CMAJ to a press release that said the proposed rules \"have the potential to be life-saving for transgender people,\" who will now be able to \"find affordable health insurance that covers the essential care they need and doesn't exclude care simply because of who they are.\" \"They are being sort of interrogated about their gender and their genderidentity and their history,\" said [Nicole Nussbaum]. \"If you skin your knee and you might need stitches, what does that have to do with anything else?\" Improving care for transgender patients might also include providing diversity training for medical staff, noted [Deanna Clatworthy]. That could help ensure transgender patients are referred to in a respectful manner in accordance with their self-identities, regardless of the names on their health cards. \"For billing, you have to use the name on the health card, but just because that's the name sent to the government doesn't mean you have to use that when referring to the patient.\" - Roger Collier, CMAJ

Essential facts Nurses feel woefully underprepared to meet the needs of transgender patients, according to an RCN survey. Despite a steep rise in numbers of transgender patients across the UK, there is a lack of training to equip nurses with the skills needed to care for them.

Background Improving access to medical transition for transgender and gender diverse (TGD) individuals is a priority, which requires data on the experience of medical transition during and after the process. However, no Patient-Reported Experience Measurement (PREM) questionnaire has been developed specifically for this population until now in the French context. The primary objective was to provide preliminary evidence of the psychometric properties regarding validity and reliability of the PREMIUM questionnaires among TGD individuals undergoing medical transition. The secondary objectives were to explore the relationships between different dimensions of the care experience during medical transition with socio-demographic and clinical characteristics. Methods A national web survey was conducted from 2021 to 2022 including a set of PREMIUM questionnaires measuring respect and dignity, information received, access and care coordination, interpersonal relationships with providers and psychotherapy. Reliability was assessed using Cronbach’s alpha and corrected item-total correlations, and construct validity was assessed through exploratory factor analyses (EFA). Univariable and multivariable logistic regressions were used to assess the association between self-reported experience with sociodemographic and clinical data. Results A total of 168 individuals participated in the study, revealing through PREMIUM questionnaires critical areas for enhancement: informational gaps on initiatives and peer support, care access and coordination challenges marked by appointment delays and repetitive medical histories, respect and dignity concerns highlighted by intrusive questions and insufficient information, as well as deficiencies in interpersonal relationships with providers, evidenced by inadequate therapeutic alliance, encouragement for emotional expression, and limited provider engagement. Additionally, the psychotherapy domain indicated a need for improved availability, choice, and effectiveness of services. The psychometric properties of the questionnaires were satisfactory with high Cronbach’s alpha coefficients (> 0.70) and adequate corrected item-total correlations (≥ 0.30). The EFA results showed that the questionnaires were essentially unidimensional. An initial consultation with a surgeon and being older at the initial consultation were associated with a better care experience. In contrast, higher educational level, an initial consultation in a private practice, with an endocrinologist, were associated with a poorer care experience. Conclusions This survey highlighted key areas for improving the experience of medical transition for TGD individuals in France. Systematic use of PREMIUM-TRANS questionnaires could enable tracking of experience-related parameters over time, providing useful insights for providers and policymakers.

The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner. Across high-income and low-income settings alike, there often remains a dearth of educational programming for health-care professionals in transgender health, although the best evidence supports introducing modules on transgender health early during clinical education of clinicians and allied health professionals. While these challenges remain, we review the increasing evidence and examples of the defined roles of the mental health professional in transgender health-care decisions, effective models of health service provision, and available surgical interventions for transgender people.