Literature Review
“Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments” aimed to answer three questions: is there a relationship between healthcare avoidance due to anticipated discrimination and gender identity/expression, what sociodemographic and transgender specific factors are associated with healthcare avoidance, and do said sociodemographic and transgender specific factors moderate the effect of gender identity/expression on healthcare avoidance? The study was a secondary analysis of the e 2015 U.S. Transgender Survey implemented by the National Center for Transgender Equality (NCTE), and found that transgender people face more barriers to healthcare than cisgender people. Because of this, providers should consider the specific needs of transgender patients to create trans-affirmative environments. In order to decrease rates of healthcare avoidance, healthcare providers need to both educate themselves on trans issues and create a more welcoming environment for transgender patients using intersectional policies. Transgender men had increased rates of healthcare avoidance relative to transgender women. This study looked at trans people as a whole but noted that trans men were underrepresented (which is very common when talking about trans issues). A quarter of the people in the study avoided healthcare due to fear of discrimination, and the majority of the people doing so being transgender men (27%). Visual non-conformity (ie, what we in the trans community call “passing”) and non-disclosure of one’s trans identity (ie, not being “out to your doctor”) significantly lowered the chances of trans people accessing healthcare, as well as factors such as race, poverty, and access to insurance. “Barriers that produce missed opportunities for preventive, general, or trans-related care may magnify the physical and mental health disparities among transgender men relative to other subgroups.” Poverty and visual non-conformity were also found to be related, as trans people who do not pass as one of the binary sexes are less likely to be employed, and though not every trans person wishes to transition, those who do often do so because they have the financial resources that are necessary.
“Female-to-male transgender quality of life” aimed to evaluate and compare health related quality of life in trans men compared to cisgender men and women in the us. This case-control used the Short-Form 36-Question Health Survey version 2 (SF-36v2) to study this population. They found that trans men have significantly lower quality of life than cisgender men and women in the U.S. Gender affirming interventions such as hrt and top surgery significantly improved QOL scores in FTM. This study helped idenitfy the health needs of transgender men in the United States, emphasizing access to hormone replacement therapy and top surgery as interventions that can improve mental health and social functioning in trans men. FTM in the U.S have significantly (p<.01) lower QOL than cisgender men and women, specifically in domains such as mental health and social functioning. This study found that physical health was significantly higher compared to cisgender adults. When controlling for age, FTM health related QOL scores were significantly lower than cisgender male scores, but not cisgender female scores. FTM who had received HRT had significantly higher QOL scores than FTM who hadn’t in areas such as Vitality, Social Functioning, Role Emotional, and Mental Health. FTM who had received top surgery also had significantly higher QOL scores than those who hadn’t in domains such as General Health, Social Functioning, and mental health. The findings of this study imply that access to these gender affirming processes allows for many trans men to construct their masculinities, which improves their quality of life.
“Do transgender men have equal access to health care and engagement in preventive health behaviors compared to cisgender adults?” aimed to compare trans mens’ access to healthcare to cisgender men and women, and how sociodemographic issues influence this access. This case-control study used the Behavioral Risk Factor Surveillance System (BRFSS) from the CDC to answer this question. The study found that Trans men overall have less access to healthcare than cisgender adults, but when controls for income, age, ethnicity, and rural residence are used, these results are not significant. What this means is that healthcare providers wishing to be more inclusive of trans men should use intersectional strategies. Trans men were found to exercise less than the average cisgender adults, and a possible explanation for this is the anxiety that comes along with public exercise and hegemonic masculine standards, in addition to the fact that those with a lower socioeconomic status tend to exercise less, and many transgender men are lower income. Trans men in rural areas were 9 times less likely than those in urban areas to say they had a doctor, meaning that outreach care for trans men in rural areas would be a worthy investment of time.
“Barriers to Health Care for Transgender Individuals” aimed to review the literature on barriers to access to healthcare for transgender people and propose research priorities to understand and overcome these barriers. This study found that the main barrier or transgender people accessing healthcare was lack of knowledge about transgender medicine (ie, hormone replacement therapy) mainly due to the fact that transgender health needs are not taught to most health care professionals. Lack of insurance and income was an other barrier to healthcare for transgender individuals, as well as “discrimination, lack of cultural competence, health system barriers (inappropriate electronic records, forms, lab references, clinic facilities), and socioeconomic barriers (transportation, housing, mental health)”. All of the data gathered for this study was done through self-report of transgender individuals, which means that research from the persepctive of healthcare providers is needed to determine their attitude towards transgender patients, to determine if this affects access to healthcare. One study that did interview medical students and medical residents found that they were much less comfortable providing hrt to transgender people as opposed to cisgender people, despite the process being the same. Studies that do examine barriers for this population look largely at the LGBTQ community, as opposed to specifically transgender people. No studies have been done on the specific care that needs to be given or the status of said care, or third party financial support.
“Gender Reassignment Surgery: An Overview'' sought to provide an overview of the several procedures used by trans people to transition from either male-to-female or female-to-male. The article is broken into segments including male-to-female non-genital surgery, male-to-female genital surgery, surgery complications for male-to-female procedures, and all of those for female-to-male procedures as well. Findings on these surgeries and processes find that gender reassignment surgeries are some of the most complicated based on factors like inexperience for many surgeons, difficulty in achieving ideal cosmetic outcomes, and psychological status of the patients who are seeking treatment. The information cited in this article came from a series of searches from PubMed and MEDLINE for original articles that included keywords like “vaginoplasty,” “gender reassignment,” “phalloplasty,” and more.
“Utilization of Health Care Among Female-to-Male Transgender Individuals in the United States” aimed to present the health and health care needs of trans individuals in the United States, and to document how often those needs are not being met due to one reason or another. A self-report survey was conducted with 122 individuals who learned about the study at the FTM Conference of the Americas in Seattle, Washington in 2001, and their responses provide the data for this study. Notable findings include that 30% (n=34) of respondents reported receiving poor or fair medical care, 49% (n=60) of respondents reported not receiving annual pelvic exams, and 60% (n=73) of respondents reported that they would definitely use a Transgender Clinic if they had access to one. Trans men are often grossly underrepresented in studies of trans needs and health outcomes, so there is a dire need for more inclusion for them in future studies. The sample for this study also appears to consist of more “well-off” trans men, as many of them are able to receive adequate health care and access to treatment(s), so there is still a need for more studies to provide a broader pool of trans men so that needs and health care realities can be more accurately assessed. Finally, there is still more need for studies of PCOS among trans men as the rates are disconcertingly high despite this study not reflecting that, and there is need for the lack of access to gender reassignment surgeries to be reflected in legislature and policies.
“The Relationship Between Medical Education and Trans Health Disparities: A Call to Research” aimed to draw a line between the lack of trans health knowledge and education in medical schools and in medical centers, and the health outcomes of trans folks, as well as their access to health care. This article draws upon several prior studies, and the findings include, but are not limited to: “Several studies link the persistence of trasngender health disparities with inadequate clinical training,” “Some medical educators have explicitly tied the adverse health outcomes experienced by many trans individuals to the lack of cultural competency training in medical schools,” and the fact that trans individuals experience higher rates of HIV infection, attempted suicide, drug and alcohol use as coping mechanism, and smoking tobacco as coping mechanism, while simultaneously having less access to health insurance (all compared with U.S. general population.) The lack of cultural competency training and lack of knowledge of the Standards of Care for the Treatment of Gender Identity Disorders are found to directly impact the health outcome of trans individuals, whether it be because of botched procedures or just that trans individuals delay seeking help or refuse to seek help due to fear of discrimination. “According to the National Transgender Discrimination Survey, 28% of trans respondents reported postponing medical care due to discrimination, and 28% reported being harassed by providers when they did seek out care.” There needs to be far more cultural competency, as well as specifically LGBTQ+ health care training in medical schools and anywhere that medicine is being practiced, as the lack of knowledge around these areas is impacting the care that trans folks are receiving as well as the quality of work that our health care providers are doing.
“Unbound,” written by Arlene Stein, is a novel that reviews a qualitative research study done in order to analyze and understand the transgender man, non-binary, and butch experience before and after undergoing top surgery. Stein follows the lives of four interviewees and evaluates how the breast removal surgery impacted their quality of life. The book provides knowledge on the lack of access that trans men have to proper care and life-changing surgeries because of race, ethnicity, interpersonal relationships with family and friends, transphobia, discriminatory insurance policies, poverty, and unemployment. Stein elaborates on the process of obtaining a diagnosis of dysphoria, undergoing the surgery, and postoperative treatment, as well as the impact that the surgery has on each interviewee afterward. The book reviews the risks of hormone replacement therapy and undergoing surgery. It displays the statistics of trans men who were denied access to their medical needs due to low income and rejection of insurance coverage. Although the healing process is rough on the body, all of the people that Stein interviewed reported having better quality of life afterward. A sense of emotional and physical relief was described, as well as a reduction of symptoms caused by mood disorders. Undergoing top surgery proved to elevate the feeling of gender performance and the interviewees reported feeling like their authentic selves after their appearance was masculinized. Activities or hobbies that are socially perceived as feminine were avoided before surgery, but post-surgery interviewees felt as if they could participate in them without being perceived as feminine due to their new physical appearance. Stein concludes that access to transgender healthcare is a necessity for relieving dysphoria and betters the lives of those who desire to have their breasts removed.
“Uncertain Expertise and the Limitations of Clinical Guidelines in Transgender Healthcare” aimed to evaluate levels of uncertainty in the field of transgender medicine due to the guidelines that evidence-based medicine (EBM) do not provide in regards to transgender healthcare. In-depth interviews of 23 healthcare providers in the United States were conducted in order to gage the effectiveness of EBM and what strategies that providers use when treating transgender patients. The providers selected for the study were professionals who worked within the transgender medicine specialty. The interview revealed that when providers are faced with uncertainty, they will turn to clinical guidelines, but their responses also would vary depending on clinical experience. Providers who followed clinical guidelines expected their transgender patients to be 100% certain of medical interventions related to their transition. The clinical guidelines that have been put in place provide a series of outlined steps that healthcare providers are supposed to follow to provide a “successful” transition for their patients. However, not every transgender person’s transitioning process is the same and these guidelines can easily fail them, so some flexibility is necessary depending on the patient. Some providers loosely follow the guidelines for the transgender standards of care or use them as a guideline in order to determine the proper care for their patient. This article provided research on uncertainties in treating transgender patients. It evaluated the preferences of 23 transgender healthcare providers, where some preferred to follow clinical guidelines without variation, and others used them as a set of guidelines meant to be interpreted based on the patient. It was concluded that EBM allows providers to feel more confident in their medical decisions, but the healthcare model did not provide a strong enough foundation in order to fully assess the needs of transgender patients. It was instead found to create a paradox that concluded in even more uncertainty of how to treat transgender health cases and emergency health situations.
“Healthcare Experiences of Transgender People of Color (TPOC)” focused on a study group from Chicago that reported on their experiences with healthcare providers as transgender patients. All of the participants in this study described healthcare experiences where providers responded negatively to either their race or ethnicity, or their gender identity. 82% of the participants often sought out LGBTQ+ healthcare clinics in order to avoid discrimination and 36% sought out healthcare providers who matched their own race or ethnicity. Finding a provider that had the most knowledge of trans-related healthcare was the most important factor where limited options were available. TPOC were found to have higher rates of HIV, attempted suicide, lack of insurance, and tendencies to avoid their healthcare needs altogether due to anticipated discrimination. Participants in this study reported encounters with healthcare providers where they stated that they were uncomfortable treating them because their were transgender. Often transgender identities were not disclosed due to the fear of transphobia. The study concluded that TPOC reportedly have more challenging healthcare experiences than white transgender or cis-gender, or cis-gender people of color.
“Gynecologic Care of the Female-to-Male Transgender Man” gave insight into the healthcare needs of transgender men who require gynecologic care. Transgender men’s healthcare needs were found to be difficult to identify because of the limited research performed, as well as the inability to identify the population of transgender men. Transgender men were found to have an increased risk of having Polycystic Ovarian Syndrome (PCOS), contracting HIV, experiencing violence, and committing suicide. Much of the transgender community often engages in prostitution as their main source of income because of transphobia in the workplace. Needle-sharing in order to administer hormones bought through the illegal drug market also put transgender men at risk. Prostitution and needle-sharing increase the risk of trans men contracting HIV. A lack of competency throughout the medical field and absence of sensitivity to trans needs, most transgender individuals will only seek out healthcare in emergencies. However, because of this, health-related problems that could have been identified prior to the emergency will go untreated and cause further harm to their bodies. Minimal research has been done on the population of transgender men, resulting in a lack of knowledge of the safety in the sex reassignment surgeries, or other care, that doctors perform. Phalloplasty and Metoidioplasty surgeries to create a phallus lack safety, intended results, and the long term health outcomes have not been researched. Transgender men do not receive the appropriate gynecologic care due to a perceived incongruence between their gender identity and their physical body. It was found to be challenging for transgender men to also receive gynecologic care because of the focus on their sexual reproductive anatomy, which caused emotional discomfort. Although many barriers were found, many transgender men do receive gynecologic care on a semi-regular basis. Gynecologic care was received when transgender men were comfortable with the staff and the staff used their proper pronouns and name. It is advised to educate patients that breast cancer is not directly related to sex or gender and to acknowledge that there is an absence of research regarding long-term effects of taking testosterone on breast tissue, in order to persuade transgender men to obtain breast exams. In order for transgender men to feel safe and comfortable enough to participate in receiving regular gynecologic healthcare, it is important for healthcare providers to be respectful, understanding, sensitive to their patient’s needs, and knowledgeable on treating transgender men.
Sources
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Stein, A. (2019). Unbound: transgender men and the remaking of identity. Vintage Books, a division of Penguin Random House LLC.
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