Research indicates that trans people face a number of barriers to healthcare, including challenges in finding healthcare providers (HCPs) who are knowledgeable about, and sensitive to, trans identity and health issues. These and other barriers contribute to this population's under-usage of healthcare services and, in turn, their poor overall health outcomes compared to the general population. This article provides research-informed recommendations to improve HCPs' cultural competence, which may increase trans individuals' utilization of healthcare and thus contribute to better health outcomes for this population.
Trans individuals are those whose gender identity does not match their sex assigned at birth. In this article, "trans" is used as an umbrella term for a full spectrum of non-cisgender identities, including transgender, gender non-conforming, and non-binary individuals.
Research shows that trans individuals often face barriers to healthcare, including finding healthcare providers (HCPs) they believe are knowledgeable about, and sensitive to, trans health issues such as mental health, trauma histories, and health concerns related to hormone replacement therapy (HRT) and gender-confirming surgeries (Dean et al. 2000; Sanchez et al. 2009). Not being able to find an HCP who is knowledgeable about, and sensitive to, trans issues is a contributing factor to the trans population's underutilization of healthcare services and may be partially responsible for the poor health outcomes prevalent in the trans population as compared to the general population (Dean et al. 2000; Grant et al. 2010; Vermeir et al. 2018).
The purpose of this article is to highlight some key recommendations for individual HCPs, healthcare organizations, and relevant educational institutions to improve HCPs' knowledge, attitudes, and behaviours with respect to trans patients. The recommendations are based on data collected through qualitative interviews with eight trans participants in Nova Scotia, Canada, which explored barriers to primary and emergency healthcare in terms of interpersonal relationships with HCPs, the physical environment, and the social environment. (See Vermeir et al. 2018 for details about the study methods and findings related to these barriers.) We recognize that eight individuals is a small number of participants upon which to base recommendations, however, the qualitative methodology provided robust, in-depth participant-focused exploration of the issues. The veracity of these findings is strengthened as a number of the recommendations concur with, or can be implied from, other studies. It is, of course, possible that different or additional recommendations may have arisen if there had been a larger number of participants in our study, but nevertheless the recommendations we present may play a significant role in improving HCPs' knowledge, attitudes, and behaviours. They may also be beneficial to HCPs working in other environments beyond primary and emergency care, as well as non-HCP staff members.
The purpose of the interviews with trans adults was to explore their perceptions of, and/or experiences with, primary and emergency healthcare, as well as their suggestions for needed changes that they believe would help to reduce barriers to access. All the participants in our study agreed to being referred to as "trans." "HCPs" were defined as the various types of providers found in primary and emergency healthcare settings including physicians, nurses and technicians. Participants reported receiving various types of healthcare within these settings including mental healthcare and transition-related healthcare. Each participant used specific terms to describe their gender identity, but three identified with the pronouns "she/her," three with "he/him" and two with "they/them." The participants ranged in age from 18 to 44 years, had varying socio-economic statuses, and all identified as white or Caucasian. The qualitative research approach of our study was informed by social constructivism, queer theory, and an environmental framework. Framework analysis and the constant comparative method were used to guide the data analysis (Vermeir et al. 2018).
As we have previously reported, participants in our study raised concerns about HCPs' lack of knowledge regarding trans identity and health issues, as well as HCPs' poor attitudes and negative behaviours (Vermeir et al. 2018). These issues, and the recommendations stemming from them (that participants either specifically mentioned or that we have inferred from their comments), fall within the realm of cultural competence, although participants did not explicitly use this term. Cultural competence is defined as the ability of HCPs and organizations to effectively understand, communicate with, and deliver suitable healthcare services to diverse populations (Wilkinson 2014). Researchers have suggested that HCPs often lack the cultural competence necessary to provide appropriate healthcare for trans patients (Baker and Beagan 2014), which is likely a consequence, at least in part, of the little to no education that many HCPs receive on trans identity and health (Beagan et al. 2015; Moll et al. 2014). It may also be related to the societal stigma that exists with respect to trans people (Lombardi et al. 2002).
There have been noteworthy critiques of the term "cultural competence," including that it is impossible to become competent in an experience that one has not actually lived (e.g., the experience of being a trans person) (Baker and Beagan 2014; Gregg and Saha 2006). However, there are components of cultural competence that are critical to providing informed and compassionate healthcare to members of diverse populations. Such components include having a sensitive understanding of how gender identity influences interactions with the healthcare system, as well as acknowledging the pervasive power differentials that exist between HCPs and patients, especially those from marginalized groups. We argue that these important components of cultural competence should be encouraged and supported through appropriate interventions. The recommendations provided in this article are intended to help improve cultural competence, and thus reduce some of the barriers to healthcare for trans patients. Some of the recommendations presented stem from barriers which we have previously reported on (Vermeir et al. 2018); however, in this article, we take these issues and explicitly state them as actionable items that HCPs can implement. We also elaborate on a couple of recommendations that were only touched upon when discussing the barriers.
Equitable access to healthcare is a cornerstone of the Canadian healthcare system, and we argue that efforts must be made to ensure access to healthcare by reducing barriers. The recommendations provided in this article are intended to contribute to the reduction and/or elimination of some of the barriers experienced by the trans population (Vermeir et al. 2018). It is also important to attend to these recommendations given that the number of people who report identifying as trans is increasing likely due, at least in part, to heightened social acceptance (Flores et al. 2016; Reed et al. 2009), although we recognize that societal stigma does still exist. The growth of those reporting a trans identity underscores the increased need for HCPs to have the appropriate knowledge, attitudes, and behaviours when interacting with trans patients.
Knowledge: Recommendations for Improvement
As we have previously reported, a number of participants spoke about HCPs' lack of knowledge regarding trans health, including that most participants had encountered an HCP who was unsure of the meaning of "transgender" (Vermeir et al. 2018). A number of our participants felt burdened by, what they perceived as, an "expectation" that they should educate their HCP about trans issues (Vermeir et al. 2018). Having to educate HCPs is a recurring issue for trans people accessing care (Williams and Freeman 2008; Xavier et al. 2007). As we have previously reported, participants recommended that HCPs should have some knowledge regarding trans identity and health, at least in terms of understanding the basic definitions and concepts, and should be willing to increase their knowledge when it is deficient (Vermeir et al. 2018). Some participants also specifically recommended that when an HCP is interacting with a trans patient, the HCP should be up front with their patient regarding their existing knowledge and prior experience with trans patients. If needed, they should increase their knowledge and show improvement over time if there are ongoing interactions with the patient. To do so, HCPs should not rely on their patients to educate them but should use reputable resources to ensure that what they learn is accurate (Vermeir et al. 2018). We recognize that searching for such resources may take some time, which can be challenging for HCPs who have busy clinical practices. However, it is critical that HCPs are using the appropriate resources. Healthcare organizations can help to lessen this task for individual HCPs by compiling and circulating a list of useful resources for HCPs to use as a starting point.
Participants in our study believed that improving HCP knowledge would not only benefit the HCP but would also allow for a positive relationship between HCPs and trans patients to develop over time, which may increase patients' utilization of healthcare services. Although it is critical that individual HCPs learn about the trans population, we believe that there is also a need for educational organizations and regulatory bodies to incorporate this topic into their curriculums and continuing education opportunities to promote HCPs' cultural competence including an acknowledgement of the power differentials between HCPs and trans patients. We appreciate that there are many topics deserving of HCPs' and future-HCPs' time and that it may be challenging to incorporate more material into the curriculum. However, the high rates of trans people underutilizing and avoiding healthcare, coupled with the poor health of many in this population (Dean et al. 2000; Grant et al. 2010), underscores the urgency of education on the topic for those in the healthcare field. Historically, the opportunities for HCPs to receive trans-health training have been deficient (Beagan et al. 2015; Moll et al. 2014), but it is necessary that this improve in order to reduce the HCP knowledge barriers that hinder the trans population's access to care. As HCP knowledge increases, accessibility to basic healthcare services, as well as the comprehensive healthcare services that some trans patients require (including HRT prescribing and management), should improve and patients may feel more confident in the care they receive. For those who feel burdened by a sense of responsibility to educate their HCPs, the increased knowledge of HCPs will likely lessen this burden.
Attitudes and Behaviours: Recommendations for Improvement
When discussing HCPs' attitudes and behaviours, participants stressed a number of what they referred to as "basic and easy" recommendations for improvement, including the need for HCPs to respect a person's chosen name and preferred pronouns regardless of whether these have been legally changed, and politely asking what a patient's preferred pronouns are, rather than assuming they know. Engaging in such practices would point to the HCPs' sensitivity to the population, which is a key component of cultural competence.
At the organizational level, intake forms in physicians' offices or clinics, for example, can be used to help gather information about names and pronouns, and many participants suggested having blank lines for individuals to write both their preferred and legal names, and their gender identity, as opposed to "male" and "female" boxes. Beagan and colleagues (2013) further suggest listing potential gender identities, such as "male, female, transgender, non-binary, etc.," following the blank line as this indicates explicit awareness of these identities. In a situation in which a gender, pronoun, or name mistake has been made, participants noted that an apology and a correction of the mistake are helpful for overcoming any negative reactions to the error. Making excuses for one's mistake may be frustrating and triggering for the patient and are to be avoided.
As we have previously reported, some participants in our study discussed their dislike of gendered terms within healthcare, such as "women's health" (Vermeir et al. 2018). In many cases, a trans man pursuing these services may be physically indistinguishable from a cisgender man. One participant discussed his experience asking for directions in a "women's healthcare" setting and remarked that he was met with surprise when HCPs realized he was the patient. He stated: "[they] didn't know that it was even a possibility [that] someone who looked like me [would be a patient]." Based on such experiences, participants recommended that HCPs avoid using gendered terms, such as "women's health," so as to not exclude the non-women who access, or want to access, these services. They also stressed the importance of HCPs being aware that individuals with diverse gender identities are utilizing traditionally "gendered" services and that these individuals should not be isolated, called-out, or rudely questioned for appearing to be "out of place." We understand that these changes may be difficult at first given that gendered care and language is ingrained within the healthcare system. However, as more HCPs work to make their language more inclusive, they contribute to a more accessible healthcare system for trans people.
Many trans people encounter HCPs who ask inappropriate questions regarding their trans identity or bodies, or questions that are irrelevant to their care. Unnecessary inquiry into such details can be humiliating (Hussey 2008; Vermeir et al. 2018). Participants recommended that HCPs remember that a patient's purpose is not to satisfy one's interest, and that even if a question is relevant to one's care, it must be asked with sensitivity and appropriateness. As noted above, such sensitivity is key to cultural competence, and cannot be overstated.
Trans people experience disproportionately high rates of harassment and violence (Doan 2010), which can have a traumatic impact on them and cause them to avoid or feel reluctant to pursue healthcare, particularly healthcare involving physical examinations (Grant et al. 2010). Notably, research shows that trans women who have biologically male sex organs often avoid prostate and testicular examinations, and trans men who have biologically female sex organs often avoid mammograms and pelvic exams (Baker and Beagan 2014; Williams and Freeman 2008). As previously noted, a few participants in our study felt that they had endured inappropriate physical examinations, and at least one participant stated that they avoid physical examinations altogether (Vermeir et al. 2018). Trans patients must be made to feel comfortable when undergoing physical examinations to ensure that they will access the necessary health screenings. Participants proposed a number of recommendations that can increase patients' comfort. Firstly, they suggested that HCPs ask the individual if there are certain terms they prefer for their sex organs. Next, they should provide a thorough explanation of the importance of the procedure and detail what is going to happen throughout. They also recommended that HCPs receive patient consent before touching them in a new location and ensure that patients feel welcome and comfortable to ask questions. Some participants highlighted the importance of patients being adequately draped throughout the examination so as to protect their privacy. One participant, in particular, shared how they had a chest and pelvic exam without adequate draping. They felt as though the HCP was "curious" about their body and that they "just wanted to have a science experiment." Changing practices to increase patients' comfort may require altering the way in which one has "always done things," but small changes can play an important role.
Some participants discussed instances where accommodations had been made for them, which increased their comfort and shows the importance of simple changes. For example, a few participants pursuing gynecological care were offered the opportunity to sit in a private room as opposed to sitting in the common waiting room, which was viewed positively. Another participant waiting for an X-ray was told that they could stay in their clothes while they waited instead of changing in a gendered changing room and then waiting in a common space while wearing a revealing hospital gown. These examples suggest that there are various accommodations that HCPs can offer to reduce patients' anxieties and demonstrate to patients that they are understanding and sensitive to their needs. Of course, these accommodations should be offered to patients and not required. For example, trans patients might appreciate having the choice to sit in a private waiting room, but being told to sit separately from other patients might be viewed as discriminatory. It is also important to ensure that these accommodations are offered in a thoughtful way, because, for example, doing so publicly could potentially "out" the patient.
Our research suggests that trans individuals appreciate when their HCPs are supportive, compassionate and understanding. Studies have found that as an HCP's knowledge of, and experience with, trans patients increases, there is also an improvement in their attitudes and perceptions of trans people (Kelley et al. 2008). Thus, we encourage HCPs, healthcare organizations, and educational institutions to take the time to learn about trans identity and health issues and implement steps to demonstrate their knowledge and sensitivity.
Trans individuals experience several kinds of barriers to healthcare including negative interactions with HCPs. In this article, we have provided a number of explicit and detailed recommendations to help improve these interactions, with a focus on increasing HCPs' cultural competence in regard to trans patients. There are, as we note, many benefits to implementing educational interventions such as increasing HCPs' knowledge including their understanding of the power inequities experienced by trans patients. However, it is recognized that changing attitudes and behaviours is not always easy or straightforward, and that ongoing education and supports may be necessary. We suggest that although it is imperative for individual HCPs to take the initiative to improve their interactions with trans patients, it is equally necessary for educational institutions and healthcare organizations to encourage better interactions and actively promote the cultural competence of HCPs.
Améliorer l'interaction entre fournisseurs de soins de santé et patients trans: recommandations visant la compétence culturelle
Les recherches indiquent que les personnes trans font face à de nombreux obstacles quant aux soins de santé, notamment la difficulté à trouver des fournisseurs de soins de santé (FSS) qui sont familiers avec les questions de santé et d'identité trans. Ces obstacles contribuent, parmi d'autres, à une sous-utilisation des services de santé par les personnes trans, ce qui donne lieu à un état de santé plus faible dans ce sous-groupe par rapport à la population générale. Cet article présente des recommandations éclairées par la recherche afin d'améliorer la compétence culturelle des FSS, ce qui pourrait accroître le recours aux services de santé par les personnes trans et ainsi améliorer l'état de santé de cette population.
About the Author
Ella Vermeir, MA, School of Health and Human Performance, Dalhousie University, Halifax, NS
Lois A. Jackson, PhD, Professor, Health Promotion, School of Health and Human Performance, Dalhousie University, Halifax, NS
Emily Gard Marshall, PhD, Associate Professor, Department of Family Medicine, Dalhousie University, Halifax, NS
Correspondence may be directed to: Ella Vermeir, c/o Dr. Lois Jackson, 6230 South St., P.O. Box 15000, Halifax, NS B3H 4R2; tel.: 902-877-1495, fax: 902-494-5120; e-mail: firstname.lastname@example.org
We would like to acknowledge Brenda Beagan for her feedback during the study. We would also like to thank the participants for their contributions.
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